Insurance companies are generally required to provide coverage for the cost of both
surgical and non-surgical TMJ treatments when a licensed practitioner believes it is medically appropriate. TMJ treatments are usually covered by health insurance companies for patients
experiencing chronic pain and under personal injury protection (PIP) for victims of car accidents.
The mechanisms of insurance coverage in TMJ cases are often quite complex and Dr.
Federman’s staff is well versed in coordinating with insurance companies to ensure that cost
should not be an obstacle to obtaining the treatment you need.
In the market for health care services, most health care costs are actually paid by third-
party entities such as private insurance companies and public health programs (Medicare,
Medicaid, etc.). Only a minority of health-related expenditures are directly paid by patients out-
of-pocket. Out-of-pocket expenses include insurance deductibles, copays, coinsurance, and out-
Common forms of health insurance include health maintenance organizations (HMOs)
and preferred provider organizations (PPOs). HMOs typically do not reimburse patients for out-
of-network care, while PPOs may cover a portion of the cost and require the patient to bear
responsibility for any fee differentials. While most patients do not directly cover the cost of their
own health care services, it is nevertheless important for everyone to at least have a rudimentary
understanding of the mechanisms of third party payers and their overall influence of health care
There are several types of health-related insurance products, including health insurance,
dental insurance, and the personal injury protection (PIP) component of auto insurance. Health
insurance may cover health-related expenditures, including general practitioner consultation fees,
specialist consultation fees, in-office procedures, surgical fees, blood tests, medical imaging,
medical devices, prescription medications, hospital fees, and physical therapy. Each procedure is
covered under a CPT code and each individual health care practitioner in private practice has the
discretion to set his or her own cash fees, discount their fees, and decide whether or not to enter
into contracts with insurance companies at their in-network fee allowance for the same CPT
codes. As a result, the same doctor may have varying reimbursement amounts for different
patients who are nevertheless undergoing the same procedures under the same CPT code at the
same facility based on differences in negotiated in-network fee allowances.
A provider or hospital that is in-network with a particular insurance company is required
to entertain all patients who have that insurance policy and charge the patient according to the
respective in-network rate for all services rendered. Deductibles are the required minimum
threshold of medical expenses at the contracted in-network fee schedule that a patient must
exceed before insurance companies fully reimburse the provider and relieve the patient of
additional financial responsibility. Copays are collected for an office visit based on the outlined
schedule in the patient’s insurance policy, and cover a portion of the total in-network fee
allowance for the consultation fee. Coinsurance is a cost-sharing arrangement in some health
insurance policies which requires the patient to cover a given percentage of the charges at the
contracted in-network fee schedule, until the deductible is fulfilled and the insurance company
must fully cover all costs in excess of the deductible.
In contrast to health insurance, dental insurance is typically like a pre-paid gift card.
Dental insurance policies typically provide full coverage for preventive services (cleaning,
examination, and x-rays) while fully or partially covering other services at an in-network
reimbursement rate up to the patient’s deductible amount. If an insured patient’s total dental
costs exceed the deductible for their dental insurance policy, the dentist is obligated to charge the
patient for the differential at the contracted in-network fee schedule, regardless of his/her cash
fees for uninsured (self-pay) patients.
New Jersey law requires all motorists to carry a minimum level of liability insurance
before operating a motor vehicle. Auto insurance companies are also required to compensate
victims of a car accident to cover the cost of evaluation and treatment for a wide range of
physical injuries under personal injury protection (PIP) coverage. Since New Jersey is a no-fault
state, your auto insurance policy will pay for care up to the maximum PIP threshold regardless of
who is at fault in a car accident.
If you have been experiencing chronic symptoms arising from TMJ, a standard health
insurance policy will likely cover most of your treatment costs. Orthodontic treatment to treat
malocclusion or tooth extractions may be partially or fully covered by dental insurance. If you
have experienced the onset of TMJ symptoms following a motor vehicle accident, please contact
Dr. Federman’s office to undergo a comprehensive exam and diagnostic imaging. PIP coverage
will probably provide full coverage for the cost of an initial evaluation. If Dr. Federman believes
that your symptoms are directly the result of a traumatic injury resulting from a motor vehicle
accident, we will work with a leading injury attorney in your geographic area to file a case on
your behalf and obtain adequate compensation from the responsible party’s auto insurance
company under their liability coverage.
For more details on PIP coverage following an auto accident in New Jersey, please refer to the
following link: https://www.nj.gov/dobi/pipinfo/origprotproposal.pdf