Frequently Asked Insurance Questions

Why haven’t I been told about periodontal disease before?

This is an understandable question. Quite simply, our bodies change. Bacterial plaque can cause decay in our teeth or cause an infection in our gums called periodontal disease. When you come in for your cleaning and exam, the dentist evaluates both the health of your teeth and the health of your gums and bone support. Just as you may have developed a cavity since your last appointment, you may have also developed an infection in your gums which may be the beginning stages of periodontal disease.

There are many risk factors affecting the onset of periodontal disease, including: smoking, diabetes, stress, medications, inadequate home care, hereditary predisposition, etc. Additionally, periodontal disease may affect your overall health by increasing your risk of developing certain diseases such as heart disease, respiratory disease, pregnancy complications, diabetes, etc. Our goal is to protect your oral health which is essential to your overall physical health.

Will my insurance cover my periodontal visits?

To give you an accurate estimate of your dental benefits we must first see a copy of your dental plan. If you bring in a copy of your dental plan, our business staff will gladly interpret it for you. Most dental plans expect to pay a portion of their periodontal visits. As a general rule, periodontal patients should expect to pay at least 30-50 percent of their treatment needs over the course of the year since most dental plans require a deductible and co-payment on periodontal services.

As you know, our goal is to provide excellent dental care to all our patients. In good conscience, we cannot ignore a bacterial infection simply because of insurance limitations. With periodontal disease, the risk is too great. If left untreated, periodontal disease not only leads to tooth loss, it may also place you at increased risk for heart disease, respiratory disease, diabetes, and, if pregnant, a preterm, low birthweight baby.

If your dental benefits seem unreasonably low, we encourage you to contact your employer and express your concerns about the limitations of your dental plan so that future dental contracts are reviewed more closely. We are happy to provide any information you need to assist you in this effort.

Why do I need to come back in 3-4 months? My insurance only covers two cleaning a year.

You have a chronic bacterial infection called periodontal disease. By measuring the pockets surrounding your teeth, evaluating the gum tissue, and reviewing your x-rays, your dentist and hygienist have discovered the infection in your gums.

As your dentist and hygienist mentioned, 1-3 mm pockets without bleeding and recession are typically considered healthy. 4 mm pockets with bleeding may indicate gingivitis or possibly even early periodontitis. 5mm+ pockets with multiple bleeding sites strongly indicate the presence of a bacterial infection called periodontal disease. The infected areas are not accessible by brushing and flossing and require your dentist or hygienist to manually remove the bacterial toxins with special instruments. The infection must be removed every 90-120 days to prevent further bone loss. Without adequate bone support, tooth loss occurs.

Concerning your insurance benefits, it is true that most dental plans allow two cleanings a year for healthy patients. For patients with periodontal disease, however, you have separate benefits aimed at arresting the bacterial infection and preventing additional bone loss. Depending on the premiums paid by you and/or your employer, periodontal benefits usually range from 30-80 percent. A deductible may also apply.

Once you have been diagnosed with periodontal disease, we are obligated to provide your dental plan with the appropriate billing codes, a copy of your periodontal measurements and sometimes x-rays. Legally and ethically, as your dental care team, we cannot ignore the infection in your mouth. Be assured that we will do our best to see that you receive the dental benefits provided by your employer.

Can’t you just change the code?

We wish it were that easy. However, there are very serious consequences for doing so.

The Health Care False Claim Act states: “No person shall knowingly make a false statement or false representation of a material fact to a health care payer for use in determining rights to a health care payment. Each claim that violates this subsection shall constitute a separate violation.”

Dentists and hygienists have a legal responsibility to select the dental code that most accurately reflects the treatment rendered. To manipulate a code to obtain better benefits for a patient is a violation of the Health Care False Claim Act and draws the attention of the F.B.I. and U.S. Postal Inspectors because false claims sent via the U.S. Postal Service constitute mail fraud.

Dental insurance phone representatives often tell patients the benefits available under their dental plans. While a phone representative may know the details of a patient’s dental plan, he/she often does not understand the legal responsibilities of the dental office. A dental representative may tell a patient what code(s) will be paid under the terms of his/her contract, not realizing that the dentist and/or hygienist can lose his/her license if he/she manipulates treatment codes in order to obtain those benefits.

Changing a code is not the answer to dealing with denied dental services. The plan purchaser, usually one’s employer, must agree to increase benefits when negotiating the dental contract.