As of July 1st 2015 medical insurance has dropped the coding for TMJ orthotic appliances. This means that there is no medical insurance coverage for the primary component of non-surgical treatment which are appliances. Medical insurance also does not have coding for the CBCT (Cone Beam CT scan) which is considered the highest level x-ray diagnostic tool for TMJ disorders. Medical insurance does continue to have benefits for the TMJ MRI which is useful in diagnosing disc disorders and TMJ arthritis. Some dental insurance plans offer coverage for a single TMJ orthotic appliance; however in many cases two appliances are needed, a day appliance and a night time appliance which have different designs. Sleep Apnea appliances continue to be a covered expense by many medical insurance plans, if the proper protocols are followed. Certain physical medicine modalities and/or injections may have benefits on the medical or dental insurance plans, however these are usually adjunct procedures to the orthotic appliances and represent only a small portion of treatment cost. Treatment cost varies from State to State, and generally the fees in the Fort Worth/Dallas area are much less than states like California, so it is not uncommon for clients to come in from other states for treatment.
The standard of care for TMJ disorders is determined by the court and by credentialling bodies of the TMJ field. There are two credentialling bodies: the American Board of Craniofacial Pain and the American Board of Orofacial Pain. Insurance companies; however do not acknowledge this field as a specialty field, and as a result they continue to offer dismal coverage. The lack of insurance coverage truly makes a negative impact on the perception of treatment being legitimate to the patient, and as a result keeps many patients from receiving the very treatment that would improve their chronic issues like: jaw pain, headaches, migraines, neck pain, etc.... It is interesting that most insurance plans that cover TMJ surgery require the very non-surgical procedures, which they don't pay for, to be accomplished prior to surgery.
Dr. McCarty is board certified by the American Board of Craniofacial Pain and by the American Board of Craniofacial Dental Sleep Medicine. He will continue to treat patients at what he believes to be the highest level of care and does not compromise standard of care based on insurance codes and benefits.
Many of our clients sign up for interest free payments through Care Credit, so they can begin the work of reducing their pain at more affordable monthly payments. If you are interested in Care Credit you can go to www.carecredit.com and prequalify. Once on the CareCredit web site select provider locator, and then under the heading "Does My Doctor Accept Care Credit" type in our phone number 817-441-6875. You may then select Apply Now. Of course our office also accepts: checks, cash, or credit cards (Visa, MC, Discover, American Express, and most HSA cards).
Dr. McCarty is an out of network provider and is not a Medicare provider. He requires full payment for services at the time of service. Because he is an out of network provider, he cannot confirm whether or not the patient will have any insurance reimbursement. His office does offer the convenience of completing the initial insurance forms for the patient, but the office does not become involved in insurance disputes. The insurance provider will be asked to reimburse the patient directly.
Medicare patients will be required to sign an “opt out” agreement and will not be receive reimbursement from their Medicare. Since Medicare doesn't pay for appliance therapy for TMD anyway, the Medicare patient doesn't really lose out. Medicare recipients that have supplemental plans are usually required to use Medicare as their primary provider, and in those circumstances should expect no help from either the primary or supplemental insurance.
An HMO type insurance will require a request by the patient from the primary care physician for an out-of-network referral authorization for the TMJ evaluation at our office. However, even if an authorization is provided, it does not change the points made previously regarding insurance coding, and there still will be no help from the insurance provider. With either an HMO or PPO type of insurance you may be required to ask for a GAP exception from your insurance company. In most areas there are no providers for non-surgical TMJ treatment that are in network; however the insurance companies will claim that there are. They will usually provide a list of providers. The patient has to call each provider on the list, ask if they provide non-surgical TMJ treatment, and document their answer. After the list has been exhausted then a complaint can be made to the insurance provider, and they will usually provide a GAP exception allowing you to come to our office. There are usually oral surgeons on the provider list given by the insurance company; however most do not perform non-surgical care. Having a GAP exception does not mean that Dr. McCarty will take assignment of benefits. HMO patients are always welcome to forego their insurance.