Why Doesn’t My Insurance Pay for This? Part 4 of 4

Over the past month we have been writing on the same topic of why one’s insurance may not pay for all the costs of dental treatment.  So far we have discussed how a dental insurance plan can make getting the dental care you need easier but does not always cover all the costs associated with prevention and treatment in the dental office.  This last blog concludes our four part series where we have been reviewing some of the cost-control measures that are taken by your dental benefits plan to keep costs low on their end but as a result, push fees back on to you as the patient.  Today we discuss what an insurance company means if they report something was “Not Dentally Necessary” as well as bundling, downgrading, and “least expensive alternative treatments.”


“Not Dentally Necessary.” Many dental plans will state that only procedures that are “dental or medically necessary will be covered.”  This DOES NOT meant that the services rendered were not covered if the claim is denied.  The decision to render this treatment was made after the professional recommendation of your dentist.  Those reviewing the claims are not necessarily dentists and do not know you and the state of your oral health.  If your plan rejects a claim you can appeal.  Your benefits manager in your HR department and the plan’s customer service department can be very helpful along with the guidance of your dental office.


Bundling.  Claims bundling is when two different procedures are combined into one by the insurance company to reduce your benefit amount.  This could be combining certain xrays to pay your dental office less or combining surfaces on a filling to again pay the dentist less.  Ironically, the dental office has to report what they do correctly or it is fraud but the insurance company can change the reporting and reimburse how they see most fitting.  This makes no sense to the health professionals and is a major issue we are constantly battling.


Downcoding.  Similar to bundling, the dental office has an obligation to report the services rendered accurately and in an honest and timely fashion, the insurance company can change the procedure to a less complex (i.e. lower reimburseable) procedure therefore reimbursing the dental provider less than the claim is for.  This is seen daily!  The procedure we see it most often with is placing white fillings on the back teeth.  The white filling materials are harder to use and much more expensive then silver but are the material of choice for most patients by their provider because of their longevity, esthetics and lack of corrosive bi-products but many insurance companies will only cover silver fillings and will only reimburse for their costs.  Not cool dental insurance companies.



Least Expensive Alternative Treatments (LEAT). If your plan has a LEAT clause and the claim reviewer feels there is more than one way to treat a condition they will pay for the least expensive treatment option.  However, this reviewer does not know the patient’s wants, needs, desires, mouth and the least expensive treatment option may not be the best for this patient.  This is commonly seen with implant tooth options versus dentures.  A location may be the perfect site for an implant tooth but your insurance may only cover tooth replacement with dentures or removable dental appliances.  These may not be in your best interest.  I highly recommend you speak with your dentist about the best treatment option for you and consider your coverage as well as third party financing to make sure you get the treatment you deserve and will benefit most from. 


In conclusion, although you may be tempted to make decisions about your dental care based on what your insurance will cover or pay for, we encourage you to remember that your health, and specifically your dental health, is the most important thing.  Dental insurance is only one part of your healthy mouth plan.  We can help you find out what you plan covers and plan accordingly.  At Katy Trail Dental, we want to work with you to help you get the treatment you need.  We are a small office and do what we can to work with our patients and work for our patients.  We want to help you, as you help us make the world a healthier place one mouth at a time!