Medical and Dental Insurance for Orthodontics

A Q&A with Jamie, our financial coordinator

Jamie has been our insurance and billing guru since 2011, obtaining medical benefits for our patients with craniofacial and cleft lip and palate conditions or who have suffered serious injuries.

Before that, Jamie had her fair share of working in the dental field during her ten years of dental assisting. She then spent several years at ODS/Moda (Delta Dental of Oregon) working in dental claims and fraud investigation.

This experience on “the other side” helps Jamie understand how to communicate effectively with insurance companies. This is probably why no one else in the state can do what Jamie can. image for section - blog main image

In this article, you’ll learn:

Medical Insurance

When can you bill medical insurance for orthodontics?

We typically bill medical insurance when we have a patient who has a craniofacial condition. We’ve even billed insurance for cases where a patient has been in a bad accident and subsequently needs orthodontics in conjunction with surgeries.

How do you help patients navigate the medical insurance process?

There’s usually not too much navigating for the patients to do, though there are some insurance companies that require the patient to do the legwork instead of the provider. In those cases, we’re here to help with the process by walking them through all the steps that we typically take. I’ll also write letters to the insurance company providing all the clinical information that they need.

Are there specific things that people should know about billing medical insurance?

One of the most important things is being aware of your own insurance benefits. Understanding what your deductible is and that depending on your deductible, approval doesn’t always mean that we’re going to get a payment. You can learn about your benefits by calling your insurance company or speaking to the HR department of your plan’s subscriber.

The best case scenario is holding on to both your dental and medical insurance throughout your entire course of treatment. Any time you change your insurance mid-treatment, you’re taking a chance at not getting any further benefit. In the case of medical billing, the whole process has to start over. The new insurance company isn’t going to just look at a claim from us and pay it.

With all medical insurance companies, Dr. Garfinkle and all orthodontists are going to be out-of-network because they are dentists, not medical providers. Some plans don’t allow you to see an out-of-network provider. In those cases, because Dr. Garfinkle is the only provider in Oregon with the qualifications that he has, we do go through a process of requesting him to be able to treat the patient. image for section - ages infographic
Dr. Judah with Kaylee, a Garfinkle Orthodontics patient who was born with a cleft lip and palate. Kaylee has had multiple surgeries, tooth extractions, and two rounds of orthodontic treatment.

What are the success rates for getting treatment approved by medical insurance?

We pulled all of our data together a couple of years ago, and our success rate for treatment approval was at about 94 percent

When a patient’s insurance doesn’t allow them to go out-of-network, what are the chances of getting medical insurance to allow them to see Dr. Garfinkle?

I would say it’s probably pretty close to our overall success rate because he has the qualifications that other orthodontists don’t have. It’s easy to show insurance companies these qualifications and that there’s really no one else in the area that the patients can see for this specialized treatment.

Once the medical insurance process begins, what does the timeline look like for patients?

It can unfortunately take quite a bit of time. I usually give it six months – mostly because anytime you have any communication with an insurance company, they then have 30 days to respond.

So that means that if I were to submit something two weeks before treatment starts, insurance might not respond until two weeks after treatment has started. At that point, the response can simply be, “we need another x-ray.” So I send that in and they have another 30 days to respond.

Sometimes it’s quicker, and sometimes it’s longer, but six months is probably the average until we know whether treatment is approved.

What is communication with the family like during this time?

I try to keep families in the loop as much as possible. Any communication I receive from the insurance company, the family will receive as well. While I do my best to keep the families in the loop, it is very helpful for the patient/parents to be proactive as well. They can always reach out to me to ask questions and see how it’s going.

What can families do to help the process?

Most of the insurance customer service agents are on the member service side, rather than the provider side. It’s difficult nowadays for us to even reach a human being on the provider side of insurance. Just calling your insurance company and asking about the status of your claim can help get them moving. Sometimes they’ll give you a little bit more information than they’ll give us.

If you really want to be proactive, you can write something to your medical insurance company as to why you believe the orthodontic treatment should be covered. Everything we submit is very clinical, so this personal statement can help put a face with a name, showing the human behind the claim. We don’t typically ask for this at the start of treatment because there is a lot of information to cover and this can be a little overwhelming.

What should a letter to your medical insurance look like?

The letter can be super short. Your child was born with this condition, this is the treatment he’s gone through so far, and this is what we need to keep moving forward.

Working with insurance companies sounds difficult

When it’s straightforward, it’s really rewarding. But when they push back, it can be maddening. It seems so straightforward to us on this side that this [orthodontic] treatment should be covered under medical insurance. These are conditions that the majority of our patients were born with and in order for their lives to be normal and functional, they need these things fixed. So when it goes smoothly and patients get that benefit, it feels good.

What is special about our practice?

It’s special that we bill medical insurance. I would venture to say that we’re likely the only orthodontic office in Oregon that is willing and capable of doing it.

How is Dr. Judah different from the other doctors you’ve worked with?

I have worked with many doctors, but I’ve never worked with somebody who is so available all the time to answer questions and help. Dr. Judah is a great advocate for our patients. We write patient insurance letters together and he always returns them very quickly so that we can get them out as fast as possible.

Dr. Judah also advocated for the State of Oregon House Bill 4128, which mandates Oregon insurance companies to provide coverage for medically necessary dental procedures for patients with cleft/craniofacial conditions.

Dental Insurance

Does dental insurance cover orthodontics?

Every dental insurance plan is different, so the best thing you can do is educate yourself about your benefits. You can get this information by calling your dental insurance company or your (or your spouse’s) HR department.

  • What is your deductible?
  • Is there a waiting period for orthodontics? (Some plans require a 90-day to a 1-year waiting period before they’ll cover orthodontic treatment)
  • What percentage of the treatment will your insurance pay?
  • What is the maximum amount your plan will pay?
  • Is this a lifetime maximum or does it renew annually? (The majority of dental insurance plans offer a lifetime orthodontic benefit that does not renew each year. Once they pay, the benefit is gone). image for section - blog main image

What are some things that people don’t consider about their insurance coverage?

Anytime you change your insurance mid-treatment, you’re taking a chance at not getting any further benefit. The best case scenario is to hold on to both your dental (and medical insurance if we’re billing medical) throughout your entire course of treatment. Many plans say if the treatment has started before the plan was effective, they will not pay.

Sometimes people cancel their dental insurance after the initial visit, thinking that they only need coverage at the beginning of treatment. But many insurance companies pay out over the course of your treatment, not in one lump sum. Even if your insurance does pay in full at the beginning, they have the right to request a refund if your plan is canceled mid-treatment. image for section - blog main image

How can we help patients with their orthodontic financial agreement?

We understand that things happen, jobs change, and life events happen. If there are times when you need to skip a month’s payment, we can be flexible.

If you need to change your payment plan because it just isn’t working out for you, we’re happy to discuss it. We tend to be able to be pretty flexible if we see that payments are coming in on time and regularly.

What about FSA/HSA plans?

As year-end comes, many people have money left in their FSA/HSA that they need to use. FSA/HSA can be very specific about what they cover and when, but orthodontics is more flexible because most treatment plans span multiple years. We can help you maximize your remaining benefits and provide you with the proper documentation so those benefits aren’t lost.

We're conveniently located in SW Portland, serving Beaverton, the Pearl District, Lake Oswego, and surrounding areas.

Erin Fortman is a long-time employee of Garfinkle Orthodontics, working as our Marketing and Treatment Coordinator. She is a mother of two young children and a former patient of Dr. Garfinkle, which provides her with a unique and in-depth understanding of the orthodontic process as it relates to the concerns of our patients and their parents.