Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

December 4, 2017

Playing games with insurance (PPO) fees


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Dr. Hall-
My dentist’s treatment plan calls for two lower 3-crown bridges for the second back tooth forward on each side. The dentist advises porcelain fused to metal crown/bridges—due to it being a stronger material to resist grinding pressures—and wants 20% additional $$ above the PPO contract rate for the “upgraded” crown materials vs. all porcelain crown/bridges.

I have three questions:
1. Which type of crown is better and will have best chance against cracking?
2. The 20% “upcharge” labeled as “lab fees” is not a covered code by my insurance. Can a dentist charge above the PPO contract rate and refuse to use the “standard ” porcelain/ceramic crown which is covered by insurance? It seems to me that it is a “work-around” the contract rate, effectively avoiding the limited contract rate fee.
Though I may prefer to have the PFM bridges if they are indeed stronger. I simply may not be able to afford this mandated “upgrade” and I do not think I should have to switch dentists as a result of this, since he is an “in-network provider.”
3. I have all porcelain upper bridges on each side, so my other concern is will the lower PFM crowns grinding against the “all porcelain” upper crowns cause the upper to more likely crack sooner, as I will have stronger material grinding against softer material as opposed to a like material against a like material? Does that make sense?
Thank you.

-Tom from Ohio

Tom,
If you are communicating this accurately to me, then there is indeed some funny business going on with your dentist trying to get away with charging above the contract rate for your bridges. It certainly sounds to me like he or she is playing games with terminology and fees. Let’s address that first.

To sort this out, we need to clarify the terminology here.

First, for the benefit of readers who may not know, a PPO is a preferred provider organization, which is a network of dentist providers that have made an agreement with an insurance company to offer discounted fees to the subscribers of the plan being offered by the insurance company.

Then, as far as the types of crowns, my guess is that your dentist, for the crowns that are a part of the bridges, is using the procedure code D6740 – retainer crown porcelain/ceramic. Notice the term “ceramic” in this procedure code. That’s important. Porcelain isn’t strong enough to serve as a bridge even on the front teeth, much less on the back teeth. It will crack under chewing pressure. But there are other ceramics that are plenty strong enough, and many dentists are now offering these metal-free bridges. I can’t help but assume that we’re talking about one of these higher-strength ceramics here and not porcelain.

But now you’re saying that your dentist wants to “upgrade” to a porcelain fused to metal crown. A couple of problems with these games he or she seems to be playing with the terminology. First, to me the upgrade would be the other way around. The higher strength all ceramic crowns would generally be more expensive. Second, there are procedure codes for porcelain fused to metal crowns and I’m sure the insurance company would have that on their fee schedule. There are three codes for porcelain fused to metal crowns: D6750, D6751 and D6752 for porcelain fused to high noble, base metal, or noble metal respectively. Now it’s possible that the PPO will not pay for the bridge if the metal is high noble. But the noble metal is actually stronger and unless they are really cheap, they should have a fee for that.

And the idea that this “upgrade” is mandatory—that seems to me to be a violation of his contract with the insurance company. The dentist can offer you an upgrade as an option, but he or she has to give you the choice of doing the service that is covered by your plan.

About your other two questions:
The porcelain fused to metal is a little stronger, but the high-strength ceramic is plenty strong enough for a bridge on back teeth.

As far as compatibility with the upper bridges, yes, you are better off having similar materials chewing against each other. Neither one is going to “crack,” but they will wear. You would be best off contacting the dentist who did the upper bridges and finding out exactly what was used on the chewing surface and matching that. You have these high-strength ceramics, but they are often made of a framework veneered with a porcelain.

Then I have a final question for you. Let’s say you tell your dentist no, you want the porcelain/ceramic crowns because you understand that is your right under your insurance plan. Will he or she give you then the high-strength zirconia ceramic? Or will you get the porcelain which won’t hold up? Bottom line—do you trust this dentist?

– Dr. Hall

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Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

November 14, 2016

Will Medicaid cover porcelain veneers for me?

Filed under: Dental insurance — Tags: , , , — mesasmiles @ 8:33 am

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Dr. Hall,
I’m a cancer survivor and am on Medicaid. I’ve been bulimic since I was 15. I’m now 52. I had porcelain veneers done in 1987 and have loved them! my problem now is my upper gums have receded due to the bulimia and the cancer. Will Medicaid cover veneers since my problem is due to a medical problem?
– Terri from Texas

Terri,
Unfortunately, Medicaid is designed to cover only the cheapest treatment that will solve any given problem, and with the cheapest materials. And at that, they never pay the provider the full fee. So you have all those obstacles.

In the minds of the architects of Medicaid, the problem with your teeth could be solved by extracting all your natural teeth and providing you with removable dentures. That they would cover. That is assuming that they buy your reasoning that this is actually a manifestation of a medical problem.

But even if they did cover porcelain veneers, they would not cover beautiful porcelain veneers. For dental procedures, they are now paying about one-third to one-half of typical fee schedules. From the start, that will cut out practically any dentist who provides quality cosmetic dentistry. And then for the dentist who is willing to take a case like that, he or she will be looking for any possible way to cut corners and deliver some type of veneer. Unfortunately, that is the state of Medicaid in the country. And still the program is going broke trying to make ends meet.

Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

September 29, 2015

Is this dentist trying to scam the insurance company?

 

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Dr. Hall,
I had three crowns done – upper and lower first molars on the left side, and lower right second molar. They were porcelain fused to high noble metal, insurance code #D2750. For $150 each, the dentist suggested I upgrade to crowns with added porcelain, so there would be no black line on my gum line in the future. On his advice I agreed.

When I got the insurance paperwork I noticed there was a charge on all 3 crowns for pulp cap direct, insurance code #D3110. Nothing was ever said to me about the pulp cap direct, so when I questioned it, his office insurance lady said that the insurance takes care of that, and whatever they don’t take care of she will write that portion off at no cost to me.

Then, two months after getting the crowns, the one on the lower right fell off. To my surprise it was a very very small partial crown. I questioned why I paid for an upgrade when there was no gum line involved, since it was such a small crown. The insurance lady told me the crown was all porcelain and the metal would have shown, if the upgrade hadn’t been done. I also asked why there needed to be a build up and why it needed pulp cap direct. She told me he had to build up the tooth and the root was almost exposed which does not make sense to me. The dentist re cemented the crown and charged my insurance company, but did not charge me. I would appreciate your feedback on my issues. Thank you so much for your time.
– Tony from California

Tony,
I don’t know because I can’t verify any of this, but all of this sounds awfully suspicious to me, like this dentist has a scam operation to milk everything he can out of the insurance companies.

And you.

I’m an accredited cosmetic dentist who saw a lot of appearance-conscious patients, and I never did porcelain margins or anything like that for esthetic purposes on lower molars, and two of these teeth you reported to me were lower molars. One was a second molar. Even if there were a black line there, no one would ever see it. In my own mouth, I have gold crowns on both my lower second molars and no one knows but my dentist and me.

And for a crown to fall off after two months? In twenty years, I never had a crown that I did fall off.

You said that the crown that came off, when you looked at it, had no metal and the insurance lady told you it was all porcelain. That makes sense, since you say it was a very short “partial crown.” Being all porcelain, it could be bonded to the tooth, which would make it stay on. But it didn’t stay on. Furthermore, the procedure code you quoted me was for porcelain fused to high noble metal (i.e. porcelain fused to gold), which would get a higher reimbursement rate from the insurance company than what it appears was actually done. And it certainly sounds like the dentist just made up that all these teeth required direct pulp caps. A direct pulp cap is a serious situation where the decay goes down to the pulp of the tooth and the dentist puts a special coating directly on the pulp of the tooth to try to save it without doing a root canal treatment. That tooth should then be watched to make sure it heals well before doing anything major like a crown. A protocol that would make sense would be to do the buildup and wait a couple of weeks to make sure the tooth isn’t sensitive and responds properly. And I would certainly expect the dentist to tell you about this at the time to tell you to let him know if you have any sensitivity afterward. If you did, then further attention would be needed. If you didn’t, then the dentist is going to want to get credit for heroically saving your tooth and saving you from needing a root canal treatment.

And that this was done on all three teeth? That strains credibility.

And the notion that the practice would write off whatever the insurance company didn’t pay, that’s an indication that this procedure is all an invention to get a little more money from the insurance.

I think this is worth an investigation by the insurance company. I’d report to them that you weren’t aware of any pulp caps. And you could also report your suspicions to the California dental board, if you have a mind to.

I’m not saying this dentist has done anything wrong—I’m saying it’s suspicious and worth looking into by the insurance company and by the dental board. If alerted, the insurance company and the dental board can demand to see the actual records and x-rays of these finished procedures and can check other patients to see if this dentist can back up his claims of what he has done.

Dr. Hall

What do you think? Do you have a comment? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

October 18, 2011

Beware of insurance plans that don’t include your dentist!

Filed under: Dental insurance — Tags: , , , — mesasmiles @ 8:56 am

I got this request from a website visitor regarding a dentist I know in Louisiana. I forwarded it to his office, but then also wrote an e-mail to the patient and thought I would share this with you. This dentist is an excellent general dentist, not in our cosmetic dentistry network, but a fine general dentist, and I felt the patient was making a mistake with the approach he was taking.

“I was Dr. X’s patient for years but unfortunately he’s not in my insurance network. I was trying to get his e-mail address to send him a list of available dental providers in Baton Rouge so he could recommend one. Thanks for your help.”
– J

Dear J,
This is Dr. David Hall. I’m a dentist who runs the company that services Dr. X’s website. I just happened to see your request, and it has been forwarded to Dr. X’s office. But I thought I’d offer a word of advice.

I have run a dental blog for many years where I answer questions by patients, and I can tell you that I have seen many sob stories of dental care that started with this move that you’re about to make – you have a dental insurance plan that doesn’t include the dentist you have trusted for years, you switched to the dentist that accepted your insurance, and that is when all your troubles started.

What is going on behind the scenes, that you don’t see, is that the insurance company is trying to cut costs. They probably approached Dr. Collins and all the dentists in the area with their discount fee plan and Dr. Collins was one of those dentists who said, no, I can’t maintain the quality of services I wish to provide and cut the corners I need to in order to accommodate your fee schedule. So the insurance company has found a group of dentists who are willing to cut those corners, and now you’re about to trust your mouth to their care.

I would think twice about that.

With most of these plans, you can see a dentist of your choosing if you’re willing to pay a little more. I’d really suggest that you look into that option.

Dr. David Hall

Links: Read more about preferred provider plans.

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

July 28, 2009

Dental insurance for dental implants

Filed under: Dental implants,Dental insurance — mesasmiles @ 3:22 pm

Dr. Hall,
I think I am a candidate for dental implants. Is there dental insurance that will help with the cost?
– Gary from Pennsylvania

Gary,
Dental insurance, if you already have it, will usually help pay for dental implants, but not very much. What most dental insurance plans will do is pay for the least expensive option for replacing missing teeth, which usually ends up being something removable – either a removable full denture or a removable partial denture. These are the most uncomfortable dental restorations.

Another point I’d like to make is that it appears that you’re looking to buy some insurance on your own to help pay for implants. If that is the case, think through what you want. It sounds like you’re thinking of trying to take advantage of the insurance company. You want to pay them a certain amount of money and then get them to pay you more money back in benefits than you paid them in premiums. Good luck trying to talk a for-profit dental insurance company into that business deal.
– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

July 25, 2009

Gum disease and no insurance

Filed under: Dental insurance,Gum disease — mesasmiles @ 3:16 pm

I was told I had gum disease and I have no insurance to go back and get this checked. I’m waiting to get some and I noticed my gum in front on the bottom is so low under my 2 bottom front teeth. They have become slightly loose and I know I’m gonna lose them. Please help! If they both come out will my other teeth move forward to fill that gap in? What do I do to save my teeth without having to lose them or get a partial?
– Nicole from Tennessee

Nicole,
Gum disease is serious and once teeth become loose from gum disease, there usually isn’t anything you can do to save them. And if some teeth are already loose, others probably aren’t far behind.

My advice if you have gum disease is to take matters into your own hands and not depend on dental insurance. Preventing gum disease isn’t that expensive—you just need to be faithful with checkups and cleanings, and then do your basic home care.

You would have been much better off had you kept up with your regular dental care. My advice to you now is to go to the dentist and try to slow down or stop the gum disease. The sooner the better.
– Dr. Hall

Click here to ask Dr. Hall a question.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

May 22, 2009

Will dental insurance help pay for bonding my daughter’s splotched teeth?

Filed under: Braces,Dental insurance,Tooth bonding — mesasmiles @ 4:49 pm

My 13-year-old daughter was born with a lack of tooth enamel. After braces her smile is straight but the two main teeth have two different colors on them – they’re splotchy looking. Will my dental insurance pay for this? It’s Anthem Blue Cross
– Pam in California

Pam,
When teeth are splotchy-looking right after getting braces off and they weren’t that way before, it’s probably because they weren’t really good about brushing their teeth while the braces were on. When you’re wearing braces, it’s a good idea to carry a toothbrush with you, because you need to get all that gunk off after each time you eat, or it will damage your enamel.

And since this is a situation that involves damaged tooth enamel, yes, your dental insurance is probably obligated to pay benefits. But there are a couple of cautions here.

First, your dental insurance is only obligated to pay for repairing the physical damage, and they will probably pay at a very minimal level. Don’t think of them as “covering” the repair, because that implies they will pay for the whole thing. Think of it as that they will “help” pay for the repair. You’ll want this done in a way that looks beautiful and natural. Your insurance is only committed to making the repair be functional.

Second, don’t let your family dentist do this. You want an expert cosmetic dentist. This may cost a little more, but the repair may involve free-hand tooth bonding or even porcelain veneers. You need a dentist-artist, and only 1 or 2 percent of dentists are artistic enough to produce a beautiful result with your front teeth.

– Dr. Hall

Click here to find an expert cosmetic dentist.
Teeth bleaching WILL NOT WORK for these splotches. Read our cosmetic dentistry horror story about how teeth bleaching made splotched teeth worse.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

April 24, 2009

Will my medical insurance pay for my dental implants?

Filed under: Dental implants,Dental insurance,Dentures — mesasmiles @ 3:50 pm

I have some dental issues with my upper teeth, missing three back teeth and have one bridge that is 37 years old. I would like to have all my upper teeth replaced with permanent denture implant. I have struggled with peridontal disease and go in every six months for scaling/root planing. I did try a partial dental plate but it made me gag, and I could never get past that or trying to eat with it in.

I would like to get an estimate for this if it can be done and it could be considered a medical condition so that my medical insurance would help pay for it.

Thank you for your time.
– Bev in Utah

Bev,
That’s a point that we don’t mention maybe as often as we should. One distinct advantage of dental implants over say a removable partial denture or a complete denture is that there is no extra hardware in your mouth, and people who are prone to gagging can sometimes have great difficulty with a plate, say, that goes across your entire palate as many dentures need to have.

As far as your insurance, your medical insurance won’t likely cover anything, so you will need to go to your dental insurance for any help. We get variations of this question a lot – “My teeth are affecting my general health, so can’t I expect my medical insurance to help pay for it?” But almost all medical insurance contracts have an exclusion clause that specifically denies coverage for any dental problems. Otherwise, even a simple cavity could be called an infection and it does affect your general health. The only exception is that medical insurance will generally cover dental damage from an accident. So if you break your front tooth diving into a shallow pool, medical insurance will generally help you pay for it. Otherwise, anything done to your teeth will be excluded from being covered by medical insurance.

We can’t give estimates for specific dental work. For that you need to consult a local dentist. We do have a page on dental implants cost to give you some general guidelines.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

January 30, 2009

A question about fees and dental insurance

Filed under: Cosmetic dentistry costs,Dental insurance — mesasmiles @ 5:15 am

Dr. Hall
I’m seeing a dentist covered by my dental insurance and need 3 crowns. I asked for a bill and see that I’m being charged the insurance rate $328 for each of the crowns but additionally I’m being charged $350 per crown for ‘Zirconia Upgrade’ and for tooth number 14 I’m being charged an additional $275 for ‘Upgrad Porc. on Molar’. What are these upgrades. Money is tight for me and I’m wondering if I need to pay $1325 additionally for upgrades. If it makes a significant difference I will take loans and do it, but I don’t want to unless it is necessary.
Thank you,
Ira in Maryland

Ira,
Whether these charges are “necessary” or not depends on you. You need to have a discussion with your dentist about this. Do you want porcelain on the dental crown for tooth #14, or will a metal crown do? And do you want zirconia crowns on the other teeth, or will the crown the insurance pays for be all right? That part I can’t answer, but I can help you know what is going on here. In the eyes of your dental insurance plan, these extras aren’t necessary, but keep in mind that they only have their bottom line in mind.

Your dental insurance plan is trying to save money to stay within a certain budget that your employer wants to pay for. And this dental insurance plan appears to me to be extra cheap. They have allotted a certain payment for a certain type of crown, and it appears to me that the dentist feels squeezed either in the costs allotted or in the types of crowns your insurance is willing to pay for, and is looking for a little leeway. (I have to admit that I’m going on sketchy information here, so I’m guessing at some things to fill in the blanks.)  I don’t fault the dentist for this. When I was dealing with a chintzy insurance company, I would give my patients the option of choosing the more expensive all porcelain crowns for front teeth because they looked so much better. But I gave them a handout that explained their options, the amount of the extra cost, and all the pros and cons of the different choices. It looks, from your confusion, like your dentist left out this step.

You are entitled to complete information from your dentist, including all of the options available and the pros and cons of each choice, to help you make an intelligent choice about these options. So ask for that.
– Dr. Hall

Related information: Read about the costs of porcelain crowns.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

July 10, 2008

Porcelain crowns are now rough/dentist on our insurance list

Dr. Hall,
My wife recently had porcelain crowns on front upper teeth. At a follow-up appointment, the dentist attempted to “buff” the crowns to make the color match color of surrounding teeth. Now her color is still off and the crowns have no shiny appearance. The dental assistant who says she was present during buffing says the color is as close a match as possible with what was available and that porcelain won’t be shiny like natural teeth. Unfortunately, the dentist is not a cosmetic dentist. We are seeing him because he’s on our insurance approved list.

Any advice will be greatly appreciated-
– Charlie from Indiana

Charlie,
A couple of points.

First, yes, you are right, the porcelain should be shiny. But it’s worse than you think. Besides looking dull, when the dentist buffed off the glaze on the porcelain, he or she made them so that now they will stain, so they will look even worse as time goes on. But a cosmetic dentist can bring the shine back with a diamond polish.

Second, you have to decide if you just want your teeth “fixed” so they are functional, or if you want them to look nice, because if you want them to look nice, you will have to pay for it. You will not get a beautiful result from a dentist that is on any insurance company approved list. Dental insurance companies make these approved lists by finding dentists who are willing to cut corners and thus cut costs. That approach is simply incompatible with good cosmetic dentistry.

My advice would be to find a cosmetic dentist near you from our list, and have that dentist bring back the shine and make these look as good as possible. The dentist you are going to may be a good “fixer,” but does not appear to even understand the esthetic problem he or she has created.
– Dr. Hall

Related links:
Read about Cerec crowns

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

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