Does Dental Insurance Cover Root Canals
September 20, 2023
Sometimes, but it depends on your plan…
Dental insurance plans can vary widely in what they cover, but many do offer some level of coverage for root canals.
Because coverage varies so much, we cannot give a clear-cut answer to the question. Instead, we’ll weigh the factors to consider when assessing how much of a root canal a particular dental insurance plan will cover.
When does dental insurance cover root canals?
Here’s what to look out for:
Type of Plan: PPO plans often provide more flexibility in choosing a dentist but may have higher out-of-pocket costs. HMO plans typically have lower out-of-pocket costs but require you to choose from a list of network dentists for full coverage.
Coverage Levels: Dental plans often structure their coverage in a tiered fashion, like preventive (cleanings, exams), basic (fillings), and major (crowns, root canals). Root canals often fall under "basic" or "major" procedures, and your share of the cost may range from 20% to 50% depending on the plan.
Annual Maximum: Many dental insurance plans have an annual maximum benefit, and all costs above this are your responsibility. Root canals can be expensive, and it’s possible to reach this maximum quickly if you require multiple procedures.
Pre-Approval: Some dental plans may require pre-approval (or prior authorization) for major procedures like a root canal. Make sure to go through the necessary steps in your plan to avoid unwanted surprises.
In-Network vs. Out-of-Network: Seeing an in-network dentist will usually be less expensive than going out-of-network. If your preferred dentist isn't in your plan’s network, you'll likely end up paying more out-of-pocket.
Waiting Period: Some plans have waiting periods for certain procedures, meaning you have to have the insurance for a set period (like six months or a year) before they will cover expenses for procedures like root canals.
Special Cases or Exceptions: Some plans may have limitations or exceptions, such as not covering root canals for molars or only partially covering the associated costs like X-rays or anesthesia.
Policy Details: Always check the fine print of your insurance policy to understand what is covered, what your copays and deductibles will be, and any other limitations or requirements.
Tiered or Stepped Coverage: Some plans have a tiered or stepped approach to coverage, where the percentage of coverage increases the longer you have been enrolled in the plan.
Riders or Add-Ons: Some dental plans allow you to purchase additional coverage, or "riders," for specific types of treatments like endodontic procedures, which include root canals.
If you're considering a root canal or have been advised that you need one, the best approach is to consult your specific dental insurance policy or speak directly with a customer service representative to understand your coverage.
If you’re a dental biller whose work involves reimbursing root canals, you may want to skip down to the final section: How to Optimize Dental Billing for ideas about how to streamline the root canal billing process.
How are root canals reimbursed by dental insurance?
Although reimbursement amounts vary depending on specific plans, the reimbursement itself generally follows a series of common steps. Here is how it typically works:
1. Preliminary Steps
Consultation and Diagnosis: The patient first visits their dentist for an evaluation, where a root canal may be recommended. X-rays are generally taken for proper diagnosis.
Pre-Approval/Pre-Treatment Estimate: Before proceeding with the root canal, the patient or their dentist's office may send the treatment plan to their dental insurance for pre-approval. This allows the patient to know in advance what portion of the treatment will be covered by insurance and what portion they’ll need to pay out-of-pocket.
2. Treatment and Claim Filing
Treatment: Once approval is obtained (if required), the patient undergoes the root canal procedure.
Billing: After the procedure, the dentist's office will either:
- Bill the dental insurance company directly, or
- Require the patient to pay up front, after which they must file a claim for reimbursement.
3. Reimbursement and Payment
In-Network Dentists: If the dentist is in-network, they often file the claim on behalf of the patient, and the patient billed only for your portion (e.g., co-pay, deductible, or any costs not covered by your plan).
Out-of-Network Dentists: If the dentist is out-of-network, the patient may have to pay for the procedure upfront and then file a claim for reimbursement. The reimbursement rates might be lower than if the patient went to an in-network dentist.
Explanation of Benefits (EOB): After the claim is processed, you and your dentist will receive an Explanation of Benefits (EOB) statement detailing what was covered, at what percentage, and what remains as your responsibility to pay.
Payment: If the dentist's office billed the insurance directly, they will receive payment from the insurance company for the covered services.
Patient's Share: The patient is responsible for any remaining balance, which could include deductibles, co-pays, or any other charges not covered by insurance.
Reimbursement: If the patient paid for the procedure upfront, your insurance will send you a reimbursement check for the covered portion once the claim is processed.
How to optimize dental billing practices
Optimizing dental billing practices is crucial for maintaining a successful, efficient, and profitable dental office. Good billing practices also contribute to better patient satisfaction, as billing issues can be a common source of frustration for patients. By streamlining your dental billing processes, you can improve cash flow, reduce administrative burden, and allow your dental team to focus more on providing quality care to your patients. It’s almost certainly worth it!
Here are some strategies to consider:
Staff Training: Train staff in the nuances of dental coding, billing procedures, and insurance claims processing. Staff should be well-versed in using dental billing software.
Clear Role Assignment: Designate specific staff members for billing tasks to ensure accountability.
Billing and Coding Accuracy
Up-to-Date Codes: Always use the latest dental procedure codes. Outdated or incorrect codes can lead to claim denials.
Detailed Documentation: Maintain thorough records of all treatments provided, including x-rays, photographs, and notes. These records can be essential if an insurance company requests additional information.
Double-Check Claims: Before submission, review claims to ensure accuracy in procedure codes, patient information, and other details.
Prompt Billing: Submit insurance claims as soon as possible after treatment.
Follow-Up: Keep track of submitted claims and follow up on any that are delayed, denied, or incorrectly processed.
Regular Audits: Conduct regular billing audits to identify and rectify any recurring issues or inefficiencies.
Upfront Transparency: Clearly communicate the costs of treatments, what is covered by insurance, and what will be out-of-pocket for the patient.
Payment Options: Offer multiple payment options and, if possible, payment plans for more expensive treatments.
Appointment Reminders: Use automated systems for appointment reminders to reduce no-shows and last-minute cancellations.
Pre-Authorization: For expensive or complex treatments, get pre-authorization from insurance providers to ensure coverage and to avoid surprises for patients.
Insurance Verification: Always verify a patient’s insurance eligibility and benefits before treatment.
Claim Appeals: Have a standardized process for appealing denied claims.
Quality Control and Continuous Improvement
Key Performance Indicators (KPIs): Track KPIs like the rate of claim denials, the time it takes to receive payment, patient churn due to billing issues, etc.
Regular Training: Keep your team updated with the latest industry practices, compliance requirements, and software tools.
Use of Technology
Billing Software: Utilize dental billing software that integrates with your practice management system. Ensure it is regularly updated.
Automate Where Possible: Use automation for repetitive tasks like sending out bills, reminders, or following up on unpaid claims.
That’s where we come in!
SuperBill harnesses the power of AI to automate key aspects of your medical billing process, like phone calls to insurers. Whether you’re a dental practice looking for a dedicated billing service, or a DSO in search of technical solutions, with SuperBill’s help you can save time and money and free up your staff to take on more pressing tasks.
Click the Get Started button to see what SuperBill can do for you!