Medical Billing faq

Virtually anything including routine dental treatment is covered under medical insurance if the criteria for the insurance plan is met. Medical insurance coverage is mainly based on why a procedure is being done and not necessarily what procedure is being done. Some common things billed are CT scans, office visits, drainage of abscess, extractions, TMJ splints, excision of infected bone, biopsies, sleep appliances, and Botox to name a few. 

All plans are billable. HMO and EPO plans have some exceptions but will only be billable on a case-by-case basis. The VA hospital, Kaiser, and Tricare are only billable if you are participating with them and Dental 2 Medical Billing does not do enrollment for these plans.

Like dental insurance, medical insurances typically ask for 30 – 45 days to complete a claim.

Some insurances require pre authorizations on specific procedures. Dental 2 Medical Billing will handle all pre authorizations. If a letter of medical necessity (LMN) is needed, Dental 2 Medical Billing will write up the LMN using applicable chart notes and documentation to send to the insurance. These LMN’s are always uploaded for the provider’s review before submitting them to the insurance.

Whether done by the office or Dental 2 Medical Billing, eligibility checks are strongly recommended for every medical case. This will aid in all appropriate measures being taken before rendering services and transparency between the provider and patient in what to expect regarding the medical benefits.

It is possible to go in network with medical insurance however, this is NOT a service that Dental 2 Medical Billing currently provides. This process can be lengthy, the reimbursements are often very low, and the procedures on the fee schedule are limited. For these reasons, providers typically find it of greater benefit to remain out of network with medical insurances.

Medicare covers claims in the dental office that are related to cancer, trauma, and sleep appliances for patients diagnosed with sleep apnea. 

Some PPO’s will send payment to the patient when the provider is out of network but typically payments by the insurance are made to the provider.

You can bill all insurances available to the patient as long as you are not collecting over your UCR fee. We always recommend billing medical insurance first since you might be contracted with the dental plan.

Yes, based on the nondiscrimination law - Legal Support: SEC.2706.  Nondiscrimination in healthcare. The Federal health care law states the following: “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminatewith respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer.” For this reason, the definition of a Physician includes Doctor of Dental Surgery or of dental medicine pursuant to section 1802(b) of the Social Security Act and Section 603 of the MPDA.

No. For any co-insurance plans the insurance expects a provider giving a discount to the patient to also give the same discount to the insurance. The discounted rate is what would be billed to the insurance and the patient's portion would still apply and need to be collected by the provider.  

There are many examples of medical necessity, and it varies per medical plan guidelines. A generalized view of medical necessity would be accidents/trauma, infection, and contributing health conditions. A claim must have a medical necessity that meets the plan guidelines to be processed successfully. For example there must be a medical necessity to bill any radiology. In dentistry a pano may be taken because the patient is eligible for it. The medical insurance would not allow this. There must be a diagnostic reason for any radiology. The diagnostic reason is noted prior to the order of the x-ray/CT scan, this explanation of why the radiology is need would be considered the medically necessity.

Deductibles vary. They can range from having no deductible to over $5,000. Typically, the common deductibles you will see depends on the major insurance plans held by patients in your zip code.

Reimbursement depends on your demographics. You must build data specific to your practice to get an idea of reimbursement for your area. This is because reimbursement is contingent upon insurance plan allowed amounts, which vary by zip code, and the type of insurance plans you see in your zip code. For example, some offices have heavy Medicare plans in their area while others have many PPO’s. Dental 2 Medical Billing will aid you in obtaining this data by keeping track of the type of plans that are common in your practice and tracking the data regarding allowed amounts and reimbursements made by the insurances over time.

A medical deductible must be met before any benefits are applied to a patient’s plan, regardless of who the patient sees. This means if a claim was fully applied to the deductible and the deductible was satisfied because of that claim, the next claim a patient has sent out while the deductible is met will see reimbursement from the insurance. This is regardless of if the same provider or a different provider is rendering services. This is both helpful to the patient and to the provider on future claims.

In network providers have a written agreement and fee schedule with the insurance that they must abide by. Any amount outside the agreed amount is written off. Out of network providers have no such agreement and therefore charge their usual and customary rate or UCR fee. Out of network providers can collect the difference of their fee from the patient if the insurance does not cover 100% of the provider’s UCR.

Yes, Dental 2 Medical Billing bills both Medicare Part B and Medicare DME. We also handle enrollments for both.

It depends on your demographics. You will want to gather data pertaining to the amount of Medicare patients you get in the office and consider the fee schedules for Medicare in your area. This will help gauge a reasonable expectation in dealing with Medicare to find the right fit for your dental practice.

It is reasonable to increase your fees for adding a service such as medical billing, however we always encourage staying within an amount that you feel comfortable collecting from the patient as the insurance expects the provider to collect the patient’s portion. . We do aid in giving practical advice in this regard when a practice is interested in doing so. We never encourage fee inflation or billing medical insurances more than your UCR. We do aid in giving practical advice in this regard when a practice is interested in doing so. 

We only charge for the work that we do, so there are no monthly rates or monthly minimums involved. All medical billing fees are disclosed in our Introductory Packet. Please refer there for any fee/contract related questions.

Yes, PPO plans are co-insurance plans, meaning the cost of the claim is split between the insurance and the patient. The insurance wants you to collect the patient’s portion. Depending on the percentage of coverage by the plan, the provider is expected to collect the difference of their fee from the patient if the insurance does not cover 100% of the provider’s UCR fee.