Ep. 718 - Medical Reimbursement for Dentists: What You Need to Know

Are you leaving money on the table by only billing dental insurance when medical insurance could cover the same procedures? Most dental professionals don't realize they can legally bill both insurance types for medically necessary treatments.

Kandra Sellers, RDH, brings over 25 years of dental industry experience as a widely respected dental coach and educator in oral systemic health. As founder and CEO of Pristine Interprofessional Academy and TIPS Medical Billing, she has dedicated her career to helping dental professionals understand the intersection of oral and systemic health while maximizing practice revenue through proper medical billing protocols.

This episode reveals how dental professionals can function as medical specialists and tap into patients' medical insurance for procedures that meet medical necessity criteria. Kandra explains the critical documentation requirements, diagnosis coding protocols, and step-by-step processes that separate successful medical billing from failed attempts. The conversation covers real-world applications from routine evaluations to complex restorative cases involving cancer patients, autoimmune diseases, and systemic conditions affecting oral health.

Episode Highlights:

• Medical necessity must be established through proper diagnosis coding, which differs fundamentally from dental billing where ADA forms don't require diagnosis codes. Medical claims cannot process without specific diagnosis codes like decay into pulp, osteomyelitis, or bone atrophy that justify why procedures were performed.
• Dentists can bill both dental and medical insurance for the same procedure but cannot submit claims simultaneously or keep payments exceeding the original fee billed. If dental pays $50 on a $100 procedure and medical pays the full $100, the practice must refund the $50 overage to medical insurance.
• Restorative procedures typically aren't covered by medical insurance except in cases where systemic conditions like cancer treatment, radiation therapy, or autoimmune diseases such as Sjogren's syndrome have destroyed oral tissues. These cases can qualify for full mouth rehabilitation coverage under medical insurance with proper prior authorization.
• Low-hanging fruit procedures for medical billing include head and neck cancer screenings, panoramic radiographs, CBCT scans, implants, bone grafting, surgical stents, frenectomies, impacted tooth extractions, apicoectomies, and root canal treatments since medical insurance understands infection management and its life-threatening implications.
• Clinical documentation must shift from simple procedure notes to medically-focused records that establish why treatments were necessary. Instead of noting "filling completed," documentation should specify "restoration placed due to carious lesion" with proper medical terminology such as calling crowns "fixed prostheses" to align with medical billing standards.

Perfect for: General dentists, oral surgeons, endodontists, and practice administrators seeking to understand medical billing opportunities and maximize revenue through dual insurance billing strategies. Particularly valuable for practices treating patients with systemic diseases, cancer histories, or complex medical conditions.

Transform your practice revenue by learning how to leverage both sides of your patients' insurance coverage while providing comprehensive care that addresses oral-systemic health connections.