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Dental Insurance Coverage

Posted: Wed Jul 12, 2017 12:43 pm
by sampaine
I'm unclear on where the line lies between what medical insurance covers and what dental insurance covers.

We are retired and have traditional Medicare and a Type F MediGap policy. We have believed that we could easily pay out of pocket for what we consider routine dental work such as regular cleanings and fillings, so we did not get dental insurance when we retired.

Recently my dentist became concerned about a spot on my tongue and sent me to an oral surgeon (a DDS) for a biopsy. I was told that the DDS was not a Medicare provider so I would have to pay for the biopsy out of pocket. It didn't cost much so I agreed. (I understand that one always has to find a doctor who accepts Medicare to have her services covered by Medicare. That's not my issue.)

However, I'm now wondering: Suppose I need surgery to remove a benign growth on my tongue or for oral cancer. Would that be covered by our Medicare/MediGap coverage? Does it matter whether a DDS or an MD performs the surgery? Or where the surgery is done? In general, what diseases of or injuries to the mouth/teeth/jaw area would not be covered unless I have dental insurance?

Re: Dental Insurance Coverage

Posted: Wed Jul 12, 2017 3:33 pm
by mouses
I can't answer your question exactly, but as someone who has had a lot sigh of dental work, I can say that the more complicated tough stuff is generally covered by Medicare.

Although doctors' billing people are often criticized, my experience is that the billing person in, for example, an oral surgeon's office is likely to be a wizard at coding things so that Medicare covers them. So you should chat with them before a surgical procedure.

As to the DDS not being accepted for Medicare work, I looked up what my last oral surgeon's degree is. He's a DMD. The web says.."The DDS (Doctor of Dental Surgery) and DMD (Doctor of Medicine in Dentistry or Doctor of Dental Medicine) are the same degrees. Dentists who have a DMD or DDS have the same education. It's up to the universities to determine what degree is awarded, but both degrees use the same curriculum requirements." I did have some of his work covered by Medicare.

One thing to keep in mind is that if you are of Medicare age and a medical person accepts you as a patient, they can only charge you a max of I think it's 115% of the Medicare approved charge. Check the charges out first. I did not know that in advance for another specialist who way overcharged me, and I discovered that there is no enforcement of this.

By the way, dental work such as crowns, root canals, implants, bridges seems to be thousands of dollars, at least in my area. I had a root canal this week, total bill about $1500.

Re: Dental Insurance Coverage

Posted: Sun Jul 16, 2017 8:43 am
by sampaine
Thank you.

Re: Dental Insurance Coverage

Posted: Sun Jul 16, 2017 10:20 pm
by toofache32
I am that oral surgeon who does multiple biopsies each week. This has nothing to do with dental insurance although there are dental CDT codes for an oral biopsy. I have never ever seen dental insurance cover this.

Lots of misinformation in Mouses post. There is no wizardry in getting Medicare to pay for something. The doctor is in-network or not and it's all known in advance. As for the 115% fee, that's only for doctors who opt in to "that form" of Medicare which allows this. Most oral surgeons are completely OUT of network so this 115% limit does not apply. When you say another provider "overcharged" you, the likely reality is that Medicare "underpaid" them. Their rates are so low (in a non-institutional setting that cannot charge facility fees) that my office staff gets paid but I do not.

I dropped Medicare last year and am not in-network. I perform lots of mouth biopsies and also perform oral cancer removal and reconstruction. For Medicare, the dental degree is eligible for in-network status, but you will have a very hard time finding an oral surgeon in network outside of an institutional/university setting. Medicare will not let me evaluate a patient a do a biopsy the same day and get paid for both. So I had people driving in from 2+ hours away for an evaluation and I had to tell them to come back tomorrow for the actual biopsy. I used to just do the biopsy anyway for free until I realized Medicare was using me to subsidize care by paying for it myself. Then if it turns out benign, Medicare would not pay for the biopsy. In other words, only after the pathology results were available would I know if I would get paid or not. 95% of mouth biopsies are benign. And "paid" is only 30% of my regular fee that everyone else pays for. Not worth it and certainly not Boglehead smart.