Expanding Insurance Coverage for Prefabricated Zirconia Crowns

A Q&A with Industry Experts on Expanding Insurance Coverage for Prefabricated Zirconia Crowns.

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Though consumers would stand in line for an innovative new technology that solves a problem or promises to improve their quality of life, insurance companies, on the other hand, move at a snail’s pace. Getting insurance companies and state insurance programs to adopt a new dental technology can be much like plowing concrete–frustrating, tedious and out right baffling. The process is usually convoluted as several experts can attest. But, here’s the good news: it is not impossible.  

Insurance coverage for Zirconia crowns like EZCrowns has come a long way, but it still has a way to go. We spoke with experts across the dental industry about the challenges, process and landscape of the complex insurance ecosystem surrounding this groundbreaking technology. Here is their advice for dentists and parents. 

Why is understanding insurance important for dentists and patients? 

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Cathy Jameson: Insurance has changed drastically over the last decade and knowing how to manage insurance is an essential business capability of a dental practice. The American Dental Association (ADA) tells us that on average more than 50 percent of revenues for practices come in the form of insurance reimbursement checks, and for some practices that number is closer to 70 percent. 

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Brenda Hansen: It’s clearly important for dental practices to understand insurance, but it is equally important for parents and patients to understand insurance. Typically, you see changes to insurance plans annually. It’s important to familiarize yourself with any changes to your plan—it could mean better coverage for better technology, something every family should take advantage of. 

When it comes to insurance, what are the biggest challenges you see for practices? 

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Roger Levin: One challenge is that reimbursement from many insurance companies is declining. We are seeing a trend going from classic indemnity insurance to the PPO level which is often about 15 percent lower in reimbursement to the doctor. Another challenge is the submission process. Practices have to submit using the right codes. They are pretty good at this, but, unfortunately, they don’t always get it right, so it takes more time, effort and more overhead to support the overall process. 

Practices have to submit using the right codes. They are pretty good at this, but, unfortunately, they don’t always get it right, so it takes more time, effort and more overhead to support the overall process. 

What is the process to garner coverage for a new dental procedure and material? 

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Charles Blair: The first step is to get an insurance code by meeting a scientific bar. The American Dental Association and the code committee will review information about the new dental procedure and verify that it’s not experimental and that it has scientific success to back it up. Over a period of two to three years, the code will become more commonplace as demand increases. Every time a code can be used and put through the system; the odds are the better it will be accepted by insurance companies. 

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Paul Reggiardo: The code really is the first step in establishing legitimacy.  Codes are important so that the dentist can record in the patient record the exact service provided. Without a code, you can’t record the procedure and the third party reimbursement is hindered. It has to be established that there is a reasonable delivery of the service. By the time the code is issued, that procedure has been done in significant numbers and by a significant number of providers.

How are new codes established? And once established does that mean insurance will cover it? 

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Roger Levin: Establishing a new code is extremely difficult. We have seen new procedures receive codes, but typically it takes some level of widespread use by the profession and time. You don’t just get a code overnight. 

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Paul Reggiardo: Requests for coding can be made by any dentist, any member of the public, a specialty organization, or the American Dental Association’s own Council on Dental Benefit Programs. It’s a very open process. Once a procedure code is adopted, then third-party benefit carriers make a determination if it will be a covered benefit under a dental policy and at what reimbursement level. 

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Charles Blair: A newer code, such as D2929 for Zirconia crowns, must be covered in the plan document. Just because there is a code doesn’t mean the insurance company will pay—it can take a year or two for it to get embedded in the plan document where it is a covered benefit. In the meantime, dentists can submit the code and if insurance companies reject it, the dentist can go back and ask for an alternative benefit, say, or a stainless steel crown. 

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Cathy Jameson: The truth of the matter is, there are still insurance companies where it’s difficult to get Zirconia crowns covered. When a majority of doctors in a particular area start filing a code for a procedure, insurance companies will come along and start paying for it. The pressure causes the insurance companies to cover. We encourage our clients to always file the D2929 code even if they know it is not covered. This is still a fairly new procedure in dentistry, so we want doctors to use this service and present it to the parents, allowing them to see the physical and emotional benefits available to their children. Even though the fee may be higher, the insurance company may reduce the fee to the equivalent of a stainless steel crown. The more doctors in an area filing a certain procedure, the more likely it will be a covered benefit. 

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Brenda Hansen: When the code for Zirconia crowns (D2929) was added, it was a big deal for Sprig because it gave our product validity in the industry and with more and more insurance companies and state medical programs reimbursing it, it has become more affordable to parents, making it even easier to make the right decision for their child. But just getting the code does not mean that Zirconia crowns are automatically covered. The level of reimbursement varies by state and plan. 

Now that there is a code, are Zirconia crowns reimbursed at the same level as other procedure options such as composite crowns? 

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Roger Levin: For privately held insurance plans, a lot of this comes down to the employer. The same insurance company might cover Zirconia crowns for one set of patients and not another depending which plan the employer has selected. 

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Nolan Gerlach: The Washington State Health Care Authority updated its Medicaid reimbursement of Zirconia crowns to equal that of composite crowns, but prior to this I noticed Medicaid was reimbursing the composite crowns at a higher rate than the Zirconia crowns. In my mind, the Zirconia crowns are at least an equal, if not better, alternative to restoring anterior teeth. Covering it at a much lower rate disincentivizes providers from using those type of crowns. On the other hand, equal coverage for the two types has further opened up what I see as a superior product or superior solution. 

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David Stanley: In Tennessee, TennCare, Tennessee’s Medicaid program, recently changed its policy to begin reimbursing patients for Zirconia crowns. Though it is covered, we are walking a fine line right now because the reimbursement for Zirconia crowns is about $7 less than it is for stainless steel crowns and pre-veneered stainless steel crowns. The Zirconia crown is a better crown and it will last longer. Multiple times we have to replace pre-veneered crowns free of charge so, I am willing to take a hit on the Zirconia crowns because we avoid the overhead charge of having to replace them again. 

Since every state and insurance plan is different, what can be done to facilitate an increase in reimbursement for Zirconia crowns in places where it is not currently reimbursed or only reimbursed at a very low level? 

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Paul Reggiardo: If the purchaser of the insurance plan asks for the benefit, then the insurance carrier can help determine the amount of premium that would cover this additional benefit. The demand must come from the patients or, in pediatric cases, from parents. If the parents make it clear to their employers that they want Zirconia crowns as a covered benefit, then the employer will have a reason to explore adding them to the dental plan coverage. 

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David Stanley: Having more dentists providing Zirconia crowns will grow the demand for the technology, and ultimately the insurance industry will catch up with reimbursing them. More dentists providing the procedure will help educate parents on their options. 

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Cathy Jameson: One key for dentists to get a benefit reimbursed accurately is a descriptive narrative. When filling out the narrative, step one is the status of the tooth. Note the size and condition of prior restoration, if any. 

Step two is to note the amount of remaining and/or lost tooth structure. 

Step three is to note any pathology or symptoms. Step four is to note any clinical observations not visible on the X-ray. Photos are beneficial. Dentists should include the words that are more likely to get coverage approval such as “decay” and “fracture” if they are applicable to the patient. The clearer the narrative the better chance at coverage. 

What advice do you have for dentists and parents regarding insurance for Zirconia crowns? 

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Nolan Gerlach: I would encourage dentists and parents to simply ask the question to their state medical group or employers. In my mind, I felt like I simply asked the right question to the right people, “Why are Zirconia crowns not being covered at the same rate?” I didn’t have any expectations as to what my simple emailed question would lead to, but with the incredibly supportive environment in Washington with The Access to Baby and Child Dentistry program (ABCD), a simple question facilitated a conversation and subsequent equal coverage of Zirconia crowns for patients age 6 and younger, as long as the dentist has completed an educational program. 

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Charles Blair: Dentists must always report the correct code. If it’s not paid, appeal it and ask for an alternative benefit. The coverage should get better over time. 

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Paul Reggiardo: It’s essential that all providers are familiar with the procedural coding system. The ADA publishes procedure codes annually, and there are a number of additions, deletions and modifications each year. 

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Cathy Jameson: If you are a dentist not familiar with Zirconia crowns, take the time to research them. The Zirconia crown materials are healthier for a child and also aesthetically superior. For us to not introduce Zirconia crowns to our clients would be a mistake. We must bring to the table what is best for the patient and best for the practice. 

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David Stanley: We are getting patients that are calling our office and asking specifically for EZCrowns crowns. They want a strong, white crown. Providing EZCrowns crowns to our patients has differentiated us from other practices and I would recommend other dentists take a look at the technology and attend courses (Sprig University for example) to familiarize themselves with Zirconia crowns and their ever-changing insurance coverage. 

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Roger Levin: It’s really about creating a groundswell by dentists and parents. When that groundswell takes place and parents are talking to employers and dentists are talking to their societies, that’s really what it’s all about. 

You are really after pressure by employers for insurance companies to look at a certain procedure as one part of standard care to ensure families have a specific option such as the Zirconia crown. It is not one person or one committee, but it is a combined effort that leads to the best reimbursement of new procedures. 

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Brenda Hansen: At Sprig we are proud of our product, and proud that insurers have begun recognizing its billing code. We are here to aid dentists and parents with reimbursement challenges and provide the educational materials they need to approach legislators and employers so we can all work together to facilitate the right conversation around the coverage of Zirconia crowns and the need for the industry to work together for coverage solutions that work. Insurance reimbursement for Zirconia crowns is just another step in the right direction to help us fulfill our vision and provide support to our customers through every phase of their Sprig experience. 

For a product with the potential to shift an industry, changing the way insurance understands the technology simply comes with the territory. At Sprig, we believe the next generation of patients need next-generation technology. We know that proactive dental practices, industry influencers, dental educators and parents have the tools to bring the insurance industry along with us.  Keep in mind the famous words of the great orator and British war leader, Sir Winston Churchill—“Never give up!” Working together, we can improve insurance reimbursements across the board and continue making this groundbreaking technology more widely accessible and affordable than ever. 

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