Part 1 - The Inlay/Onlay Dilemma - Challenges

Some dentists will recommend or offer the option of either an inlay or onlay for patients in an effort to stay more conservative when treating teeth. This approach effectively aims to preserve teeth that have incurred partial damage. However, a common hurdle arises when submitting an insurance claim, only to encounter denials or service downgrades from the insurance company.

The Insurance Company Perspective

To understand why this happens, let’s focus on a clause that appears in many dental insurance policies: the Least Expensive Alternative Treatment (LEAT). This is the downgrade clause, which states that for select procedures, if there is a viable alternative that costs less money, insurance will only reimburse for that less expensive service. The most common example of this is when a composite filling is done, and insurance reimburses for an amalgam.  

For members seeking further insights into downgrades and effective strategies for managing them, I encourage you to watch this on-demand course: Downgrades Explained 

If your office is “in network”, filing an inlay or onlay will often result in insurance downgrading to a filling, or even disallowing the higher service fee of an inlay.

In the case of an OON office, both inlays and onlays typically get downgraded and reimbursed as fillings, meaning the patient is paying a vast majority of the treatment cost even with their insurance benefit.  

Financial Impact to the Patient

Here is a chart that shows what can happen with fees:

Let’s say an office does an onlay for a patient, which subsequently gets downgraded to a composite filling by their insurance carrier. Your $800 network fee gets paid at 80% of $150 ($120), leaving the patient out of pocket $680 or 85% of the treatment fee.

The scenario is even worse if your office is OON with a $1,400 onlay which gets downgraded to a composite filling, resulting in reimbursement of $240 for a filling (80% of $300), leaving the patient with an $1,160 expense.

The solution to this dilemma is understanding a bit more about how the coding definitions work as there are a good portion of these restorations that could get reimbursement which can save your patient’s significant money. Join today to access Part 2 of this series: How to Get Insurance Coverage.