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TMJ Diseases & Disorders - Insurance
Insurance Considerations
Have your medical or dental providers told you that a procedure or treatment is covered by your medical/dental insurance, only to discover later that the treatment was not covered, and you are responsible for the balance? People who are seeking treatment for TMJ diseases and disorders should be aware of the billing practices of their providers in relationship with their insurance carriers. Just as you would scrutinize your bank statement, careful attention should be paid to your Explanation of Benefits (EOB) from your insurance company and billing statements from your provider(s).
The explanation of benefits from your insurance company should show the amount of expense submitted by you or your provider, the coverage amount (reasonable and customary cost for the treatment/procedure), and the rate at which coverage was applied to the expense. Keeping copies of claims forms, maintaining an accounting of charges from your provider and payments from both you and your insurance company, and being familiar with your insurance EOB can help you avoid unethical office practices and confusion regarding treatments and costs.
Some providers are members of HMO's (Health Maintenance Organizations) and will accept a co-payment from patients who are insured by the HMO, billing the remainder directly to the insurance company. Some HMO policies have fee schedules and coding for treatments and procedures which the doctor must agree to in order to participate in the plan. However, this does not mean that a provider does not charge more for a treatment and/or procedure than what the HMO or insurance company considers "reasonable and customary." You may be responsible for the remaining balance. Providers who do not participate in an HMO may request payment in full, reimbursable to the patient after insurance has applied coverage and paid benefits to the physician. Therefore, by knowing your providers' policies regarding your responsibilities for payment of fees, you protect yourself from unknown debts.
Before undergoing any treatment, patients should check with their insurance company to confirm and record the coverage rate and code number for the procedure and to obtain necessary referral or approval numbers, if applicable. For most indemnity plans, the coverage rates range from 80-100%, with an applied deductible. You should review the reasonable and customary charges for the treatment or procedure with your provider. This will allow you to recognize any charges which may be more than customary cost of treatments (i.e. charges which may not be covered). Costs for procedures which are 20-30% more than the reasonable and customary charges should be investigated and scrutinized.
The following are links for TMJ insurance coverage provided by Aetna and Cigna.