volume 36  |  No. 2  |  2025

Advancements in medical insurance billing

Patients are increasingly aware of the oral systemic connection and seek financial support from their medical plans. Comprehensive treatment with the oral physician can be enhanced by filing medical benefits, even if you remain fee-for-service. Here are four shared questions about starting medical billing:Why bill medical insurance?

• When to file for medical instead of dental?

• How to start and simplify the process?

• Avoiding Medicare issues.

The U.S. Surgeon General’s report, Oral Health in America, in the year 2000 highlighted the link between oral and general health.¹ Oral exams can show signs of immunologic diseases, endocrinopathies, hematologic conditions, systemic infections, and nutritional disorders. Studies have also linked periodontal disease with diabetes, heart disease, stroke, and adverse pregnancy outcomes. Early diagnosis and treatment can be achieved by recognizing these oral symptoms. Family physicians should understand these connections and coordinate care with dental or medical specialists as needed.

Informed patients are now requesting medical billing for dental procedures to reduce financial costs. Dental professionals must navigate medical benefits and ensure diagnoses meet medical necessity criteria. This approach can improve patient care and collaboration with medical providers, bridging dental and overall health. Accurate documentation and knowledge of medical policies are crucial, especially for cases requiring medical intervention over dental procedures.

First, verify medical benefits to understand coverage and out-of-network options. If satisfactory, discuss reimbursement expectations. Then, document chief complaints, exam findings, and diagnosis in Subjective, Objective, Assessment, and Plan (SOAP) format to complete the medical claim. Software can simplify this, and many practices outsource billing to save time and focus on patient care.

Medical plan policies detail coverage criteria for treatments. For patients with functional impairments who can’t tolerate dentures and need soft or liquid food, other billable procedures include exams, radiographs, frenectomies, mucositis, myofascial pain dysfunction (Botox®), third molar extractions, obstructive sleep apnea and TMJ appliance therapy, bone grafts, and implants. Read the contract before doing medical billing.

Collaborate with the medical provider for billing reasons. Patients must complete their medical history, but provider interaction with notes and diagnostic codes is essential. Know the exact codes, medication names, and patient risk scores.

 Example: Subjective Complaints Medical Policy: Oral implants may be covered if trials of mandibular prosthesis fail and there are issues like malnutrition, a diet limited to soft foods, persistent pain, mucosal hypertrophy, or upper intestinal problems.

Example: Bone Graft Medical Policy: Coverage for oral surgery may be available under medical or a few dental plans, determined by reviewing diagnostics and medical necessities.

Medically Necessary: Procedures are deemed medically necessary if they address significant functional impairment and can improve it. Your documentation and collaboration with a medical provider work wonders in getting covered.

Reconstructive: Procedures are considered reconstructive when intended to correct a significant deviation from normal due to injury, disease, trauma, treatment of a disease, or congenital defect. Note: Not all benefit contracts/certificates cover reconstructive services. Benefit language takes precedence.

Medically Necessary:

Mandibular/Maxillary (orthognathic) surgery is considered medically necessary to treat a significant functional impairment when the procedure can be expected to improve the functional impairment. Significant functional impairment includes any one of the following (I, III, or IV below): Make sure you document why the need the treatment and the outcome.  If it is a medical reason, it is best to get the medical doctor to understand that the diagnostic reasons, he feels it is necessary.

• Dysphagia when all the following criteria (A, B and C) are met:

• Symptoms related to difficulty chewing such as: choking due to incomplete mastication, or difficulty swallowing chewed solid food, or ability to chew only soft food or reliance on liquid food; and

• Symptoms must be documented in the medical record, must be significant, and must persist for at least 4 months; and

• Other causes of swallowing or choking problems have been ruled out by history, physical exam, and appropriate diagnostic studies;
  or

• Speech abnormalities determined by a speech pathologist or therapist to be due to a malocclusion and not helped by orthodontia or at least 6 months of speech therapy.
  or

• Intra-oral trauma while chewing related to malocclusion (for example, loss of food through the lips during mastication, causing recurrent damage to the soft tissues of the mouth during mastication).

• or
  Masticatory dysfunction or malocclusion* Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth.

Document complete or partial tooth loss, matching atrophy to diagnostic reasons such as bone loss, infections, or other major medical conditions to support your findings. You must learn how to use the SOAP format for documentation and visit the site for medical providers that are learning why they need to refer patients to oral providers so you can get the necessary information you need from them.

Visit the website that teaches the medical world about the oral collaboration. Also get a free online tool for Risk Assessments. If you don’t get it, you are missing a valuable tool to back up your diagnostics and treatment plans.

Ms. Taxin serves as an adjunct professor at the New York University (NYU) Dental School and Resident Programs for New York City Programs, and is founder and president of Links2Success, which delivers continuing education seminars for dental and medical professionals.