Some Basics of Coverage and Out of Pocket Fees

• In Network vs Out of Network

  • Being in network with your carrier (or “taking your insurance”) simply means that we provide services to the subscriber at a discounted/negotiated/contracted fee.

  • Being out of network only means that we have no contracted or discounted fees with your carrier, so you would be responsible for the regular office fees.

    • Out of Network Coverage: Just because Apex Oral Surgery doesn’t have a contract with your insurance carrier does not mean insurance won’t pay anything. In fact, most plans offer out of network, usually at slightly lower percentages of coverage (see below) at slightly higher fees.

• Amount of Coverage:

  • If you are using insurance, it’s very difficult to know what your expected out of pocket is without more information. We would need to know what percentage of the insurance/negotiated fee they cover, which is determined by your group number. It’s all very individualized, but in general, the most common coverage amounts we have seen historically across all plans are as followed:

    • 80-100% coverage for diagnostics (like X-rays, Consults, Exams, etc.).

    • 50-80% for Surgery and Anesthesia ( Extractions, sedations, biopsies, etc.)

    • 0-50% for implants and bone grafting procedures. 

  • The only way to know the amount of coverage is to call your insurance company’s customer service number and ask them. We always do this for you too, but it does take us a few days to get in touch and have them give us a response.

  • We can definitely give you a MAXIMUM cost you would ever see with us (which is just the sum of the insurance negotiated rates) without taking any consideration for what % your insurance will contribute to.  It’s a sticker shock to see them, which is why we don’t like to send them, but just know it’s extremely unlikely that your insurance wouldn’t pay anything towards the responsibility. 

• Policy limitations; Generally plans only pay out $1000-3000 per calendar year per patient for all claims; if your insurance funds for the year are already exhausted, the patient has to make up their difference until the contracted/negotiated amounts are satisfied. Also, Most plans limit the number of diagnostic services in a certain amount of time; for example, they might only pay for an X-Ray if you haven’t had one in the last two or three years, or only allow 2 exams per year, etc. 

• Patient Responsibilities:

  • It’s intricate, but essentially it can be summed up in a few sentences. The surgeon provides a service at a discounted rate, and after that, it is up to the patient and the insurance company to satisfy the entire discounted/contracted fees for all services, even if the insurance winds up not covering any costs.

  • Dr. Cappetta is very reasonable, and will try to help you out as best as he can to reduce your out of pocket costs. 

  • The best thing to do is schedule a consultation with him, and our insurance team will take care of the rest. We try our best to have NO surprise costs, and we give treatment plans for all procedures. We also offer no-interest payment plans for any out of pocket costs exceeding $500.

Billing and Insurance Coverage for Specific Procedures:

• Biopsies: Biopsies performed at Apex Oral Surgery are billed in two separate parts, since more than one provider is involved in your care.

  • Surgeon’s Fee (Apex Oral Surgery)

• The oral surgeon bills for: Removing the lesion, and Handling and preparing the specimen for laboratory analysis.

• Our office will always make every effort to obtain benefits from both your dental and medical insurance plans. We will submit a claim to your dental insurance, and we will also provide a printed medical insurance claim form with the required documentation so it can be submitted to your medical insurance as well. That said, insurance coverage is not guaranteed. Based on years of experience, insurance companies can be inconsistent in how they process and pay biopsy-related claims, even within the same plan. Coverage may come from dental insurance, medical insurance, both, or neither, depending on your individual benefits and how the claim is reviewed.

• Pathology Fee (Laboratory Services)

  • Your specimen is sent to an independent pathology laboratory, where a pathologist examines it under a microscope. The pathology lab will bill your medical insurance directly for this service.

  • The laboratory participates with a large number of medical insurance plans, and in most cases, this portion of the biopsy is covered by medical insurance.

• Extraction Estimates:  Dental extraction costs and coverages vary tremendously based on how impacted they are (or aren’t), so without an X-Ray to submit to insurance, we wouldn’t really know what charge they will consider. These procedures are usually covered under most dental plans at around 80% of the fees listed below. Medical insurance may contribute, but only towards highly impacted wisdom teeth.

  • Please note that these fees are for the extractions only, and do not factor in the cost of any exams, X-rays, or anesthesia options.

• Aetna: $300-600 per tooth 

• BCBS: $200-450 per tooth

• Delta: $300-650 per tooth

• Metlife PDP+ Plans: $450-950 per tooth

• Some Guardian Plans:   $450-950 per tooth

• Some Principle Plans: $450-950 per tooth

• Some United Plans: $450-950 per tooth

• Out of Network: $500-1,000 per tooth.

• Exams,Consultations, X-rays, CT Scans:

  • These services are usually categorized by insurance companies as “Preventative” or “Diagnostic” Services. These services are usually covered at 100% and no deductible is required. This is why you usually don’t pay anything for your yearly exam and cleaning, or maybe even a small cavity filling at your general dentists office.

  • However, most patients do NOT have an unlimited number of exams/consultations or X-Rays to use. Typically a patient is only covered for two exams per year, and one full-mouth X-Ray every 3-5 years. So, hopefully by the time you get to Apex Oral Surgery, you still have remaining exams and X-Rays to be picked up by your insurance. If not, the patient must cover the contracted cost of the exams and X-Rays.

  • Interestingly enough, all insurances require an x-ray in order to complete a claim for the vast majority of oral surgery procedures, and yet they may not pay for that x-ray! It’s not right what insurance companies can (and do) demand, but we are on your side and we will do everything we can to reduce your out of pocket costs.

  • Please note that Exams/Consultations and X-Rays are never complimentary.