Are you hitting speedbumps with billing medical insurance? Or are you brand new to medical billing?
Medical billing requires that we think a bit differently about insurance. It’s not hard, it is just different. Once you get the hang of it you will be submitting successful claims in no time.
Each of these four areas must be understood to be successful.
- Medical Necessity
- Treatment Presentation
- Claim Submission
We will be discussing Coding, Treatment Presentation, and Claim Submission in future blog posts.
Medical Necessity: It’s all about the WHY!
Any procedure you do, could be billed to medical, if it’s for the right reason. It’s all about the WHY. Did you do a procedure to repair a tooth, or for a medical reason, what’s the why? Are you worried about adjacent teeth moving or supraeruption or function and change in anatomy? By simply looking at each procedure and asking, does this check more dental boxes or more medical boxes, you can determine if it’s appropriate to look at medical insurance. I refer to this as your dental glasses versus your medical glasses.
A few examples:
Patient has a missing posterior tooth
Patient has periodontal disease
You need to understand that medical doesn’t care about teeth. In fact, if you reference a tooth condition on a claim they may deny it. Medical insurance just wants to see the medical relevance, whether it’s medical symptom, medical cause or medical condition. Medical symptoms may include pain, infection, and malfunction. Similarly, if a patient has acid reflux, has been involved in a trauma, or has taken certain medications, this could be considered a cause. In the perio example above, the fact that the patient has a medical condition, like diabetes or pregnancy, and the untreated periodontal disease could be exacerbating an existing medical condition, this has medical relevance.
Providing medical relevance doesn’t necessarily prove medical necessity. I could argue medical relevance on treating any type of decay or infection and for any type of restorative procedure, as removing bacteria, caries and infection has a medical beneficial to the patient. However, medical insurance would not necessarily consider this necessity, they would consider this a dental issue, and refer back to dental insurance. Certainly doesn’t have a preventative approach, as if the patient was left untreated and their condition escalated, then we may be able to prove medical necessity. But of course, we would never delay treatment on a patient for the purpose of gaining insurance approval.
Once you and the provider have mastered the medical glasses, you will see each patient and each procedure just a little differently. In future blog posts, I will continue to fill in the blanks and the details. Stay tuned for a cheat sheet of dental diagnosis codes that can turn your average dental case into a medical slam dunk!