When Will Insurance Remap to FMX?

Insurance can be frustrating on a good day, but even more so when they change your “correct” coding and end up reimbursing nothing because of it. The patient inevitably ends up blaming you for fact that their insurance policy is not covering what it should. Surprise bills are good for no one.

A particularly common scenario is when an office files 4 BWs and 3 PAs, nowhere near the traditional FMX (full mouth series of x-rays) number of films, and then ends up receiving no reimbursement because the insurance company “remapped” the x-rays to an FMX, a coding situation which was under a 3-to-5-year frequency limit.

The way to anticipate and avoid this outcome is to know when insurance companies will and will not remap your x-rays to a different code. The good news is that you can create a simple spreadsheet in less than an hour to identify and clarify this tactic ahead of time. By doing this you can either modify what you are doing or correctly bill the patient upfront and ensure no surprises.

Insurance policies treat an x-ray sequence as a simple formula: If the price of the films adds up to more than an FMX, it will be remapped to an FMX.

Let’s take an example fee schedule:

• 4 BWs: $50

• 1st PA: $30

• Additional PAs: $15 each

• FMX: $100

If you filed four BWs and two PAs it will add up to: $50 + $30 + $15 = $95. Since $95 is less than $100, there will be no remapping.

Now, if you take that same insurance fee schedule and file four BWs + three PAs: $50 + $30 + $30 = $110. This policy will now remap your BW and PA x-rays to an FMX and cap the cost at $100. This will either prevent reimbursement if the patient has a history of an FMX, or it will start the FMX frequency and therefore prevent reimbursement for a panoramic x-ray later. Depending on the fees, some companies will remap at 6, 7, or 8 x-rays.

What options do you have to avoid this problem?

1. Bill Patient Upfront: The easiest solution is to inform the patient in advance that there will be services that insurance won’t reimburse and have the patient pay out of pocket.
2. Modify Xray Sequence: An alternative solution is to anticipate when these situations will arise and potentially modify the number of x-rays you take in a single day. It is a lot better to get reimbursement for $95 with only 6 films than it is to get $0 reimbursement by taking a 7th film and trigger a policy’s frequency limitations.

The same principle applies when you are taking panoramic images. If you are taking BWs at the same time, those BWs are not going to be covered. If you are OON, you should know this and bill the patient upfront. If you are in-network, it might be a good idea to take the pano and BWs on two separate dates of service so that you do not end up doing a lot of essentially free BWs.

By knowing more about how dental insurance works, you now have the power to better control the outcome.