When dental insurance came into existence, a treatment code system was implemented to communicate between the provider (a dentist) and the insurer as to what procedures were completed for a patient. The insurer would then, according to a “fee schedule” reimburse for that treatment code. This system made sense…at least at the time it was initiated in the 1970’s.
As years go by, dental procedures change and ideally, as new technology and new and improved procedures are introduced, the insurance company’s fee schedule would change to include the new procedures. However, this is usually not the case. Insurance companies are resistant to changes in their coding system – it can take more than several decades to add a new procedure code to the list. Why? Because adding codes means additional claims are eligible for payment, and insurance companies would pay out more money.
The out-of-date fee schedule is what I call the “insurance magnet”. Periodontal providers, limited by a signed contract with an insurance company, are drawn toward rendering treatment within the confines of what has been included on the fee schedule. If a procedure is not on the schedule, it is often not even considered as an option for that patient, even though it may be the appropriate treatment. In essence, the coding system controls what treatment is rendered, as opposed to what providers diagnose or what patients might prefer.
In short, the coding system, rather than the diagnosis, too frequently dictates the care. Isn’t this a case of the tail wagging the dog?
How can patients be sure they are given every option available? By asking their provider, “ARE THERE ANY OTHER TREATMENT OPTIONS? I WOULD LIKE TO KNOW – EVEN IF THEY ARE NOT COVERED BY MY INSURANCE”.
If a periodontal provider does not offer to do alternative treatments, it may be time to seek a second opinion.