Will Insurance Cover My Gum Graft?
One of the most common questions we receive from patients is whether or not insurance will cover the treatments they need. First, it is important to understand what dental insurance is, and how it differs from other kinds of insurance. With in-network providers, dental insurance companies have contracts with dental providers that dictate what level of fee may be charged for various procedures. These negotiated fees are based on algorithms and averages that disregard the most important parts of dental care: quality of care and the patient experience. Financial pressures from the low insurance reimbursement rates may negatively affect the quality of care a dental office is able to provide.
That is why at Northern Virginia Periodontics, we do not participate with insurance companies and are considered out-of-network providers. Our primary focus is for our patients to receive the highest quality care possible. As a fee-for-service office, we believe it is important to treat our patients based on their individual clinical needs rather than arbitrary “limits” determined by insurance companies.
Our designated treatment coordinators will file your insurance claims as a courtesy so that any benefits you may be entitled to will be reimbursed to you directly by your insurance company. When filing for you, our insurance coordinator will attach the required documents to your dental claim for processing. This includes a photo, periodontal charting, x-rays, and a specific narrative detailing the measurements and necessity for the soft tissue grafting procedure. With this information, the dental claim is still subject to review by the insurance company. Please note that most insurances will only cover soft tissue grafting in areas where there are 3 millimeters or more of recession present. Additionally, there are often other internal insurance company requirements with respect to patient anatomy, which we are not privy to, that must be met for coverage to be considered. In our experience, insurance companies generally cover less than 50% of the cost of gum grafting procedures performed in our office.
As with other dental procedures, insurance coverage for gum grafting can vary based on the details of your specific insurance plan. (Your specific insurance plan is born from an agreement between your employer and the insurance company.) Although we can’t provide exact figures/fees as to the insurance reimbursement you should expect due to the many different factors that play a role, we are happy to send a predetermination or preauthorization to allow your dental insurance company to provide you with an estimate of coverage.
An overview of relevant terms is provided below to help you understand your specific plan:
Calendar Year Maximum: Every insurance policy will have a calendar year maximum of benefits available for coverage. The average insurance maximum dollar range per calendar year is $1500 – $2500.
Coverage Limits: Dental insurance plans often have coverage limits for different procedures. Soft tissue grafting may be categorized as a periodontal or surgical procedure, and coverage may be subject to annual or lifetime limits.
Out-Of-Network Providers: Certain insurance plans (PPOs) may provide limited coverage for treatment received from Out-of-Network providers. As these Out-of-Network providers are fee-for-service, payment is required from the patient to the providing office at the time of treatment, and a claim will be submitted to the insurance company for reimbursement to the patient. (Subject to review)
Waiting Periods: Some dental insurance plans have waiting periods before coverage for certain procedures, including soft tissue grafting, becomes effective. It’s essential to be aware of any waiting periods associated with your specific plan.
Documentation And Codes: We will submit claims to the insurance company using specific procedure codes. It’s crucial to ensure that the documentation accurately reflects the necessity of the procedure for coverage purposes.
Exclusions: Dental insurance plans may have exclusions for certain procedures or conditions. It’s important to review the policy documents to understand any exclusions related to soft tissue grafting.
*Disclaimer: Northern Virginia Periodontics does not file with medical insurance unless the need for treatment is accident-related, or if a biopsy has been performed*
