Medical & Dental Insurance Coordination: What You Need to Know

Medical billing in dentistry is one of the most talked-about—and most misunderstood—topics right now. During this Office Hour, we walked through how medical and dental insurance actually differ, when coordination is required, and what it really takes for an office to get paid by medical. The goal was simple: separate hype from reality and give you a framework to decide if this is worth implementing in your practice.

If you weren’t able to attend live, here’s a recap of the most important concepts and practical takeaways from the session.

The Big Picture: Medical and Dental Are Opposites

One of the biggest problems offices run into is assuming dental insurance works like medical.

It doesn’t.

In fact, they are almost exact opposites:

• Medical: high deductible, no max, covers major events
• Dental: low deductible, low max, covers routine care

This is why patients constantly expect dental to behave like medical—and why those conversations often create frustration at the front desk.

If nothing else, your team needs to understand this difference so they can explain it clearly and confidently to patients.

Why Patients Are Confused (and How to Respond)

Patients are used to:

• Paying a co‑pay for visits
• Hitting a deductible and then having everything covered
• Not worrying about annual maximums

None of those are true in dentistry.

Dental operates on co‑insurance (percentages), has strict maximums, and often runs out of benefits quickly—especially with larger treatment plans.

This mismatch in expectations is where most communication breakdowns happen.

Predeterminations vs. Preauthorizations

These terms are often used interchangeably—but they are not the same.

In Dental:

• Predeterminations are not guarantees of payment
• They simply estimate what might be paid
• They often reduce treatment acceptance significantly

In Medical:

• Preauthorizations are required and binding
• If approved, they generally guarantee payment

This is one of the biggest mindset shifts when dealing with medical. If your team treats preauthorizations like dental predeterminations, you’re going to run into major issues.

When You’re Required to Bill Medical First

Some policies—especially combined medical/dental plans—require that you bill medical before dental for certain procedures.

Most commonly this applies to:

• Wisdom teeth removal
• Surgical extractions
• Trauma-related cases

In many offices, the goal isn’t to get medical to pay—it’s simply to get a denial so the dental claim can be processed correctly.

Tools like Availity can help you submit those claims without adding unnecessary friction to your workflow.

What It Takes to Actually Get Paid by Medical

This is where things start to get more complex—and where most offices underestimate the work involved.

To successfully bill medical, you need:

Credentialing

If you are not credentialed, you will not get paid. Period.

Medical Coding

You’re moving from:

• ~200–300 dental codes (CDT)
  to
• thousands of medical codes (CPT, diagnostics, modifiers)

Even though only a subset applies to dentistry, it’s still a significantly higher level of complexity.

Different Documentation

Medical billing is built around SOAP notes:

• Subjective
• Objective
• Assessment
• Plan

This is far more detailed than typical dental documentation—and often the biggest operational hurdle for practices.

Medical Is About the Story—Not Just the Procedure

In dental, payment is tied to what you do.

In medical, payment is tied to why you did it.

For example:

• Implant due to decay → unlikely to be covered
• Implant due to trauma → often covered

This applies across multiple areas:

• Surgery linked to infection or pain
• Perio tied to systemic conditions (like diabetes)
• Full mouth reconstruction tied to medical issues

If you can connect the procedure to a medical condition, your chances of reimbursement increase dramatically.

Where Medical Billing Can Be Valuable

Medical billing can make sense in offices that regularly provide:

• Surgical procedures
• Periodontal treatment tied to systemic health
• Implants and full mouth reconstruction
• Sleep apnea treatment
• High-end diagnostics like CBCT

Unlike dental, medical often has:

• No annual maximums
• No frequency limits

This creates significant upside—but only if implemented correctly.

The Reality: This Is Not a Part-Time System

Medical billing is not something most practices can “dabble” in.

It typically requires:

• A dedicated team member or outsourcing
• Significant training
• Consistent workflows
• High case volume in the right procedures

If you’re only doing occasional qualifying cases, it may not justify the cost or complexity.

A Critical Warning: Avoid Fraud

One of the biggest risks in medical billing is improper fee setting.

You cannot:

• Bill insurance more than you would charge a cash patient

If your normal fee is $4,000, you can’t bill $10,000 just because medical might pay it.

This is a common mistake—and one that can lead to serious repayment issues.

Final Takeaways

Medical billing can be a powerful addition to the right practice—but it requires a completely different approach:

• Understand that medical and dental operate differently
• Focus on the “why” behind treatment
• Be prepared for increased complexity and documentation
• Treat it as a full system—not an occasional add-on

When implemented correctly, medical billing can increase revenue, reduce patient out-of-pocket costs, and differentiate your practice. But it has to be done intentionally.

Watch the Office Hour Recording: Medical & Dental Insurance Coordination