Medical Billing in the Dental Sleep Practice: Myths and Obstacles to Payment

June 7, 2022

Dentists throughout the US have avoided using medical billing at their practices. However, 88 percent of dentists are worried about their patients’ ability to pay for services. And while Americans are required to have medical insurance, more than 130 million of them lack dental coverage. It’s no wonder that many people have put off dental care—so much so that the CDC estimates that the US loses $6 billion in productivity because of oral health issues.

So, why aren’t all dentists using medical billing at their practice to help with payment? Perhaps the greatest obstacle to dentists in medical billing is a lack of knowledge. There are many myths and misconceptions about medical billing. While many are easily avoided, they may prevent dentists from implementing medical billing in their practices and from succeeding with medical reimbursements for their services. In this blog, we’ll explore six of the most common myths that have prevented dental practices from diving into medical billing.

MYTH #1: Dentists can’t bill medical insurance.

Dentistry has isolated itself from medicine. Even though dentists are licensed healthcare providers, the perception that dentistry is outside of medicine persists. That perception is partly perpetuated by the existence of dental insurance: Dentistry, the logic follows, is paid by dental insurance, while medicine is paid by medical insurance. The reality actually lies within the scope of our license.

The American Dental Association has defined the scope of dentistry as

the evaluation, diagnosis, prevention and/or treatment (nonsurgical, surgical or related procedures) of diseases, disorders and/or conditions of the oral cavity, maxillofacial area and/or the adjacent and associated structures and their impact on the human body; provided by a dentist, within the scope of his/her education, training and experience, in accordance with the ethics of the profession and applicable law.

Note that this defined scope does not even include the word tooth. The practice of dentistry is not limited to teeth. As such, our services are not limited to reimbursement by dental insurance. As licensed healthcare providers practicing within the scope of our license, services rendered beyond teeth are reimbursable by medical insurance.

MYTH #2: Medical billing is hard to do. 

Like any new skill or protocol implemented in a dental practice, medical billing will not succeed without the proper planning and training. Some learning has to occur, and systems have to be established to create a smooth workflow. However, once established, medical claims become repetitive and routine.

MYTH #3: Medical billing is only for practices with CT.

Absolutely not! While it certainly makes sense for practices with CT to bill medically, CT is not a requirement for medical billing. There are many other services billable to medical insurance beyond CT. These include, but are not limited to, the following:

  • Exams
  • Consultations
  • 2D radiographs (such as orthopantograms, lateral cephs)
  • Trauma to the maxillofacial area (including teeth)
  • Surgical and surgical-prosthetic procedures
  • Appliances (TMD and bruxism)
  • Durable medical equipment (sleep apnea appliances)
  • Physical (oromyofunctional) therapies

So, while CT is an excellent example of a service that can be billed medically, dentists can also bill a variety of forms of care.

MYTH #4: Staff won’t have time to do this.

The idea that medical billing is overwhelmingly time-consuming is a common misconception. It’s true that training and case selection play a large role in the successful implementation of medical billing in the dental practice. (For example, protocols and systems must be established in the practice.) However, while an investment of time is necessary to succeed, once done, medical billing operates as smoothly as any other system in a practice.

MYTH #5: I don’t need to learn medical coding because I only file dental claims. 

The revised ADA dental claim form (v2012) includes the use of medical diagnosis codes, diagnosis pointers, and place of service codes exactly like the AMA medical claim form. Dentists and dental practices are going to have to explain WHY treatment is necessary and not just detail service rendered.

MYTH #6: High deductibles will prevent payment.

This myth is based on a lack of knowledge about what a deductible actually represents. The federal government defines “deductible” as

The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself.1

It is a fact that the deductible is not applied to every procedure. The application of the deductible is a policy-specific provision and varies from policy to policy. Rather than asking: “What is the deductible?” a better question is “How will the deductible be applied?”

Consider the case of a $500 claim to a policy that has a $1,000 unmet deductible. If the deductible is applied to all of the procedures on the claim, no payment will be made; however, if the deductible is not applied to the claim, payment will be made. Therefore, a $1,000 deductible that is not applied to a $500 claim is completely irrelevant.

Further, a trend in medicine involves shifting away from the full application of a deductible in January when the deductible “resets” to a piecemeal application throughout the year. The assumption that a deductible will be applied to your claim is not true. With that being said, the application of a large deductible to a small claim will stand in the way of payment. However, this is more of a product of the quality of the insurance policy than anything else. Low-quality, inexpensive medical insurance will generally apply the deductible more often than higher-quality, higher-cost plans. You truly get what you pay for!

Perhaps the biggest obstacle to payment is the inability of a dental practice to clearly identify what should and shouldn’t be billed to medical insurance. Case selection is an important component to success. Medical billing by a dental practice does not try to get medical insurance to pay for dental procedures. Remember, some of our practice is dental in nature (teeth) and some of it is medical (the other stuff). Unfortunately, the perception that any procedure performed by a dentist is a dental procedure is pervasive. Nothing could be farther from the truth. And it is those services “beyond the teeth” that should be billed to medical insurance. With clarity in case selection, success is increased and frustration is decreased.

About the Author

Dr. Farrugia practices TMD and dental sleep medicine in Destin, Florida. He is a diplomate of the American Board of Sleep and Breathing, published author, and recognized expert on medical billing. Contact him on his website (www.successfulmedicalbilling.com) or at [email protected].

In part three of this series, Dr. Farrugia will explore the importance of medical billing for Vivos therapies.

Dr. Farrugia will be teaching a two-day medical billing course/workshop at TVI on August 5 and 6, 2022. For more information and registration, visit www.cezoom.com/registration/?conf=1230.

1 Healthcare.gov