When a dental professional thinks of Oral and Maxillofacial Surgery (OMS), they aren’t just thinking about wisdom teeth removal and jaw reconstruction.
No—as a dental professional, you know that when it comes to OMS, the person who handles billing is dancing between both medical and dental insurance claims, using their unique skill set to choreograph as much coverage as possible for their patient.
OMS billing is even more complicated than general dental practice billing because of its multiple insurance policies and different procedure codes.
To dig even deeper into why oral surgery billing is so different from general dentistry billing, we spoke to our OMS Business Unit Manager at DCS, Angela Moorman-Rakestraw, to get the scoop.
What makes OMS billing special? Let’s take a look…
1. The complex nature of OMS services
Regular dental services like cleanings, fillings, and crowns are part of routine dental visits, and most of the time, these are classified as preventative care.
OMS steps into a different realm, dealing with more complex surgical procedures that require specialized care.
Our OMS Business Unit Manager, Angela, explains:
“OMS procedures are a very wide range, from simple removal of a baby tooth to orthognathic surgery and/or facial reconstruction. Coverages not only fall under dental plans, but also medical plans, in most instances. It is very important that benefits are reviewed for all active plans.”
The need for oral surgery can sometimes begin at a general dentist, who then refers the patient to an oral surgeon. This transfer of information, from one place of business to another, can add a layer of complexity.
Luckily, with technology, this shouldn’t create complications. But it does mean the OMS team must be sure the necessity for the treatment is clear and specific on the insurance claim’s attachment and notes. This also affects the order in which dental and medical insurance claims are filed. This, of course, is known as coordination of benefits (COB).
Under COB, when a patient comes in for surgery due to an accident, the primary insurance would actually be determined by how the accident happened.
For example, if a patient lost a tooth in a car accident after that tooth was replaced, the claim would be filed with their auto insurance as the primary insurance. In fact, most auto insurance policies include medical benefits.
Related: 5 rules to remember for successful oral surgery billing
This is just one of many factors an OMS billing team must always consider that a general dental team rarely does. Let’s get more into what happens when a patient is covered by multiple insurance policies and how that impacts billing workflows.
2. Multiple insurance coverages and a stricter reimbursement model
In regular dental billing, we often deal with standard dental insurance policies and their relatively predictable reimbursement rates and patient co-pays. OMS billing, however, dances to a different tune.
As we mentioned before, OMS billing frequently involves navigating the murky waters of both medical and dental insurance coverages. Also, the costs are higher, and the reimbursement models vary significantly.
Angela says:
“Some dental insurance companies require predeterminations or pre-authorizations on certain procedures as well. Although it is not necessary to send a pre-determination on all treatments, we do recommend sending one for implant-related procedures, as there are so many exclusions on plans.”
A predetermination is a claim form for proposed services not yet provided that the dental team submits to the insurance provider. In return, the provider will send an estimate of the coverage and the patient’s out-of-pocket cost. Because oral surgery can get expensive, and your team is handling multiple insurance claims for each procedure, it’s crucial to your patient that your insurance verification process is seamless.
“All OMS offices should have a system in place for insurance eligibility and verification to occur prior to any procedures being performed,” Angela advises.
To clarify: This means your team has a consistent workflow to verify both the patient’s dental and medical insurance, and all other necessary insurance coverage, 2 to 3 days before their visit.
This will not only increase the reimbursement rate of your insurance claims, it will also help you communicate transparently with patients on what they can expect to pay. With an effective process to manage predetermination, your team will create more claims revenue for your dental business, and a more trusting relationship with patients.
Related: Insurance claims for oral surgery denied? Here are 5 reasons why...
3. OMS billing’s coding complexities and special requirements
We saved everyone’s least favorite for last: Coding.
While standard dental codes — Current Dental Terminology (CDT) — are used in regular billing, OMS billing requires a blend of both CDT and medical codes: International Classification of Diseases, 10th Revision; and Current Procedural Terminology (ICD-10-CM and CPT, respectively).
This mix increases the complexity and also the scrutiny and regulatory requirements when submitting insurance claims.
Angela offers an example:
“There are many codes that cross-code from medical to dental. For instance, let’s say a patient needs an excision of a soft tissue lesion. This should be filed to medical as primary with a copy of the pathology report. Once that claim is processed, you can then send a crossover claim to the dental with a copy of the medical explanation of benefits (EOB), and the pathology report. Most dental plans will allow for benefit coverage of this type of procedure.”
As you can see, this type of claim submission with medical and dental coding knowledge can become complex!
If your OMS team struggles with coding correctly, and faces frequent claim denials because of it, then your team, your patients, and your practice would benefit from partnering with OMS billing experts.
Related: CDT codes vs CPT codes: What’s the difference?
All insurance claims require documentation, but in the OMS space, it’s an even more essential requirement. Insufficient documentation is a common mistake made among OMS teams when submitting these complicated claims, resulting in denied claims and delayed payments.
Our OMS expert Angela warns:
“Without having the proper documentation to send with a claim, you are automatically filing the claim knowing there will be a loss of revenue and/or a delayed processing time. Lack of documentation could include not noting a drill was used to section tooth parts for complete removal. This could lead to a downcoded tooth for loss of revenue.”.
She lists what proper documentation entails:
“With OMS billing, it is imperative to send documentation with all surgical claims. This documentation should include a preoperative panoramic X-ray, an operative report, and an anesthesia report, including the drugs pushed, when applicable. This complete list of documentation helps ensure a clean claim has been filed, and the insurance company should not request any additional information for processing.”
Specialized knowledge in coding, compliance, and billing best practices is a necessity for oral surgery billing — your revenue depends on it.
Leverage your new knowledge of OMS billing vs dental billing
To recap, an oral surgery billing team faces challenges that regular dentistry billers rarely do:
- The complex nature of OMS services
- Multiple insurance coverages and a stricter reimbursement model
- OMS billing’s coding complexities and special requirements
Now that you have a clearer picture of the challenges that OMS teams are up against due to the elaborate dance steps of their billing and insurance claim management, let’s consider what this means for your dental business…
Oral surgery billing is intricate by nature, and the knowledgeable, experienced staff needed to submit clean OMS claims successfully can be hard to come by — particularly with our nationwide staffing shortage. Take a load off your OMS team by bringing on our trusted group of experts in oral surgery billing. At DCS, we serve dental practices and oral surgery practices of all shapes and sizes. Book a call with us now to collect more and worry less.
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