Member Q&A: Re-Cements, Secondary Insurance, Patient Balances & More

This month’s Office Hour was a straight-up open Q&A with no set theme, just your questions. And you all came with some great ones. A few of these I get asked almost daily, and a couple others surface just often enough that I know they're tripping up a lot of offices. Here's a rundown of what we covered, with the key takeaways for each.

1) How do we manage low fees on re-cementing crowns?

First thing I want people to understand: a re-cement visit is never just one code. Nobody walks in, you slap the crown back on, and that’s the whole appointment. You’ve got a limited exam, PAs before and after cementation (those are separate codes), and then the re-cement itself. All of that should be billed every single time.

Now, beyond the codes, think about why the crown came off. A lot of the time it’s hyper-occlusion: the crown is hitting harder than it should because the surrounding teeth have worn down over the years while the porcelain or zirconia hasn’t. That may require an occlusal adjustment, which is its own separate code (insurance generally won’t pay for both the re-cement and the adjustment, but that just means it becomes patient responsibility, and you still charge for it). Many of these patients are also good candidates for an occlusal guard, which treats the source problem and adds legitimate production to the visit.

One thing I always recommend: document and communicate to the patient that re-cementing is not a guarantee, the original source of the problem may still exist, and a new crown may ultimately be needed. This protects you if the crown comes off again, and it naturally leads to a new crown being on the treatment plan, which is good for everyone.

Here’s the insurance angle that trips a lot of offices up: some policies (and it’s a growing number) will reset the frequency on that tooth the moment you submit a re-cement. If that happens, insurance may not pay for a new crown when the time comes. So if you think this crown is likely to need replacement, have a real conversation with the patient. It may be worth not involving insurance in the re-cement — yes, they pay a little more out of pocket now — so that the frequency clock doesn’t get reset and the new crown benefit stays intact.

2) What code do you use for the one-month re-evaluation after an SRP or full-mouth debridement?

This question came in as a quick code lookup, but I want to say something first: if you're not doing a one-month re-evaluation after any non-prophy periodontal procedure, please stop letting insurance dictate your clinical decisions. The AAP recommends a four-to-six-week re-eval. It's clinically important, and skipping it just because insurance won't pay is the wrong call.

Now, the actual codes. After an SRP: it’s a re-evaluation exam, a periodontal maintenance, fluoride if you use it, and Arestin or another minocycline antibiotic if you use it. After a full-mouth debridement or generalized debridement: same exam and fluoride, and then depending on how the patient responded, it may be a prophy, another 4341/4346, or an SRP, because if they didn’t change their habits, they may not have improved enough to step down.

That one-month visit is often more important than the original cleaning. The cleaning itself is almost the least impactful part of the equation. What changes outcomes long-term is education, accountability, and catching the patient while they’re still motivated. The six-week visit is your clinical proof that what you did worked, and your best opportunity to have that "come to Jesus" conversation with patients who still have room to improve.

3) Primary and secondary insurance: what are the rules?

I get some version of this question almost every single day. Let me give you the core principles clearly.

The patient is always responsible for the lowest of the two network fees — whichever plan has the lower contracted fee is what the patient’s total responsibility is based on. It doesn’t matter which plan is primary. I see offices get this wrong constantly, and it leads to over-collecting from patients, EOB errors, and unhappy people.

That said, many secondary policies coordinate benefits in a way that allows the office to collect up to your full submitted fee, sometimes even above your primary network fee. This is completely legitimate and is not an overpayment. The only actual overpayment situation is if the combined insurance payments exceed your full office fee; in that case, the overage goes back to the secondary carrier.

One rule I cannot emphasize enough: always submit your full office fees on every claim, every time. There is zero reason to submit a network fee. In fact, it may actually be a breach of your contract to do so. And submitting full fees is what opens the door to secondary paying more.

4) Should we dismiss a patient who owes us money, or send them to collections?

The prevailing wisdom you'll hear in a lot of dental forums is: if they owe you money, dismiss them. I respectfully disagree with that, and here's why.

You're already not getting the money. Why would you also lose the patient?

We had a patient come back this year who hadn’t been in for seven years, owed us around $300, balance had been written off to "uncollectible" on our books. She came in as an emergency. She paid the old balance. She also got $1,200 in same-day treatment. That happens more than people think when you keep the door open.

It is dramatically easier to collect from a patient sitting in your chair than it is to collect from someone you’ve dismissed. If a patient owes you money but isn’t rude and you’re otherwise happy to see them, keep them. Require prepayment for future treatment, yes. But dismissing them almost guarantees you never see that money again. Keeping them at least gives you a shot, and often that shot pays off.

Dismiss patients because they're abusive to your team, because they're disruptive, because they're genuinely bad fits for your practice. Money, in my opinion, is not a good enough reason.

5) How do we handle patients who want to decline X-rays, especially when insurance requires them?

The instinct most offices have is to explain why X-rays are clinically necessary: standard of care, diagnosis, liability. For some patients that works fine. But for the ones who are truly pushing back, it usually doesn’t change anything. They’ve already made up their mind, and telling them it’s your office policy just makes them think they can find a different answer somewhere else.

What's worked consistently for me over the last decade: agree with the patient, and then redirect to something outside your control.

I'll say something like, "I completely agree — it's your body and you absolutely have the right to decline. Unfortunately, the state doesn't give me that flexibility. State law ties these requirements to my dental license, so it's not something I can work around." When you frame it that way, they can't argue with you because you're on their side. And they can't argue with the state because the state isn't in the room.

I've had two patients in ten years ask to see the actual law. I printed the full Texas State Dental Act and handed it to them. Both are still patients. Neither brought it up again.

The insurance version of this is even simpler: "You can absolutely decline the X-ray. But your insurance won't pay for the crown without it, so the total today would be $1,700 instead of $800. What would you like to do?" No argument. No conflict. Just information — and the patient makes the rational choice.

6) If a patient maxes out their insurance but wants to continue treatment, do we still have to honor network fees?

Short answer: yes, in most cases.

Hitting the annual maximum does not end your contractual obligation to honor the fee schedule for covered services. The only exceptions are a handful of states where, by law, the insurer loses fee control after maximum (check the state law section of the site to see if yours is one of them). There are also a small number of contracts where the language specifically defines "covered" in a way that excludes services beyond maximum, but those are rare.

For the vast majority of offices, across the country, after maximum: you still charge network fee. You just don’t have to file a claim (unless you’re with Delta, which is its own situation). The patient pays you directly, with less admin and no waiting on reimbursement.

The key takeaway: not filing a claim does not mean you’ve exited the contract for that patient. You agreed to network fees for covered services, and "covered" includes services that will be reimbursable again in the future, like after January 1st when benefits reset. The only clean way out is dropping the network entirely.

Members: Watch the Recording Now

These were all great questions, and the live back-and-forth always surfaces nuances that are hard to get from a written summary alone.

Keep the questions coming—this is exactly what these sessions are for!