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Patient’s insurance covers 4 prophies per year for perio instead of periodontal maintenance visits?

A patient recently transferred to our office from the local periodontal office. History of SRP and surgery 10 years ago and has been on 3 month perio maintenance visits since. Patient came in with a an insurance plan and requested to have 3 prophies a year instead of periodontal maintenance visits.

In the patient’s insurance benefits, prophylaxes is covered at 80% (we are not in network), and it states that “Cleanings are payable twice per benefit year. A third prophylaxis is payable per benefit year with a documented history of periodontal disease and a fourth prophylaxis is payable for two consecutive benefit years following periodontal surgery.” Periodontal maintenance is covered at 60% twice a year.

Obviously, the patient would prefer to be charged for a prophy, but we were taught not to alternate codes or charge a 1110 when they are a 4910. How do you explain this to your patient when they know they have perio but see it in writing in their insurance plan that they can have a prophy instead?

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1 Answer

I would explain to the patient that by law you have to bill for what is done based on the state of the patient’s oral health. A prophy is a preventive procedure, where perio maint. is to maintain health after periodontal disease. With previous periodontal disease, you just cannot treat them as if they never had it. You must treat the patient, not treat them according to insurance coverage. If the insurance wants to downgrade perio maint. to a prophy, that’s up to them, but for you to do it, it is fraud. Does the patient want to commit fraud or have you commit fraud? I would suggest to the patient that if they have questions on why their insurance covers (or doesn’t cover) certain treatment, they should contact them directly, as you have no control over that. Insurance is such a pain!

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