Third Party Payers:
Be assured that the Academy of Maxillofacial Prosthetics has been engaged for years with the United States Medicare and Medicaid system in defining procedures and diagnoses to benefit patients' reimbursement. All private carriers use codes and definitions of procedures that have been implemented by Medicare and Medicaid, however the coverage of various procedures is based on the contract between the patient and the third party. Even if a procedure is a "covered procedure", the amount of reimbursement is varied from insurance carrier to insurance carrier and region of the United States.
Not all maxillofacial prosthodontists accept insurance, Medicare or Medicaid. Accepting third party payment usually requires that the prosthodontist be a subscriber or participator of record with the third party carrier. This is especially true for Medicare and Medicaid. There are also many procedures that may be specifically denied by the carrier. Often the patient wants the prosthodontist to describe the procedure as "medically necessary", or the patient feels that the dental problem is a result of the cancer or accident. However the description of the medical necessity of the procedure, and the coverage of the procedure, is usually dictated by the insurer or federal/state government contract. The contract is between the patient and the third party payer. In fact, it is illegal for a prosthodontist to charge Medicare for certain procedures, the prosthodontist knows have been previously denied by Medicare. In these situations, the patient is responsible for the fees for the services. Usually repair of teeth are not covered by any third party medical insurer.
When going to the prosthodontist for care, a patient may be requested to sign a waiver or contract that states that the patient will be responsible for the cost of the procedures performed. In the case of insurance carriers, it may be possible to achieve a preauthorization for reimbursement, but this will depend on the agreement between the patient and prosthodontist, and contract between the patient and insurer.
These documents and links are intended to inform you of issues, sequelae, and treatment options related to various diagnoses and maxillofacial prosthodontic treatments that may interest you. The information is not intended to suggest or dictate treatment or outcomes, but may serve to begin a discussion with your physician and prosthodontist.