Oral surgery includes a range of surgical procedures that are conducted in the mouth and jaws, including removal of wisdom teeth (third molars) and corrective jaw surgery.
Oral surgery can be performed by a general dentist or an oral surgery specialist (Oral Surgeon or Oral and Maxillofacial Surgeon).
Wisdom tooth extraction is one of the more commonly claimed Oral Surgery services under private health insurance policies. Typically, a general dentist or an oral surgery specialist will perform the wisdom tooth extraction and this may be completed under either a local anaesthetic in the operator’s private rooms or under a general anaesthetic as an in-patient in hospital.
The most common ways to have teeth surgically removed are:
- by a general dentist or oral surgery specialist in their private rooms as an out-patient service; o
- by a general dentist or an oral surgeon specialist as a surgical procedure in hospital as an in-patient service usually under sedation by a general anaesthetic
When claiming health fund benefits for surgical tooth extractions, it is important to be aware that in most cases, the amount of your benefit will be determined on the basis of the provider of the service, i.e. whether it is a general dentist or an oral surgery specialist; and whether you have the procedure in the operator’s chair or you are admitted to hospital as an in-patient.
What Benefits Will I Receive From My Health Fund?
Below is a table which indicates whether you can expect to receive a benefit towards your oral surgery procedure, based on the type of cover you have.
This information applies if you have an appropriate level of Hospital cover and/or General Treatment cover that includes cover for wisdom tooth extraction, and if you have completed the appropriate waiting periods (usually 12 months).
I’m having my wisdom teeth surgically extracted in the operators private rooms as an out-patient
Either a Dentist or an Oral Surgeon can perform a wisdom tooth extraction in the chair at their dental surgery. This is referred to as an “out-patient” or out of hospital service. As an out-patient service, your health fund may pay dental benefits under your General Treatment (Extras) cover, provided your level of cover includes benefits for wisdom tooth extraction.
Before undergoing any treatment, you should ask your general dentist or oral surgery specialist to provide you with a quote, preferably in writing, of their fees and services. The quote should include the dental item numbers for the procedure, which usually consist of 3-digit numbers, the cost of the procedure and the name and provider number of the dentist or oral surgery specialist.
Once you have a written quote, contact your health fund to check your benefits. Any difference between the benefit amount paid by the fund and the fee quoted by your dentist or specialist will be your own expense.
Depending on your health fund and your level of cover, surgical tooth extraction is usually considered to be “Major Dental” treatment and you need to have the correct level of dental cover to obtain benefits. In some cases, a health fund may consider this to be “General Dental” treatment and benefits will be paid from your General Dental benefits. Major Dental treatment usually has a waiting period of 12 months or more, while the waiting period for General Dental treatment is around 2 to 6 months. It is important to be aware that if you do not have General Treatment (Extras) cover and you have your teeth extracted by a general dentist or an oral surgery specialist as out-patient treatment, you will not receive a benefit from your fund.
I’m going to hospital to have my teeth surgically extracted.
If you are admitted to hospital to have any teeth extracted under general anaesthetic by an oral surgery specialist or general dentist this will be considered an “in-patient” service and you will need to have both Hospital and General Treatment (Extras) cover to receive maximum benefits. Wherever possible, you should always check with your health fund and doctors before proceeding with surgery. Please note that rebates for oral surgery specialists are generally higher than those for general dentists, reflecting their different fee levels.
Is my surgery covered at the hospital where my general dentist or oral surgery specialist is planning to admit me?
Provided that you have the appropriate level of Hospital cover and you are being admitted to one of your fund’s agreement hospitals, your health fund will cover the cost of your hospital accommodation and theatre fees.
What benefits am I entitled to for the cost of the general dentist’s or oral surgery specialist’s fees?
When being admitted to hospital for tooth extraction, your general dentist or oral surgery specialist will use 3-digit dental item numbers, which means your health fund will pay benefits towards the cost of his or her fees under your General Treatment (Extras) cover, provided your level of cover includes surgical tooth extraction.
Prior to admission to hospital, you should request an estimate of fees from your general dentist or oral surgery specialist and check that you understand the costs you will be required to pay before consenting to the procedure (this is called giving informed financial consent). Along with the general dentist’s or oral surgery specialist’s fees, the quote should include the dental item numbers for your wisdom tooth extraction.
What about the anaesthetist’s fees?
If you have appropriate Hospital cover, your fund will also pay benefits towards the costs of the anaesthetist. Generally you will receive 75% of the Medicare Schedule Fee from Medicare and the remaining 25% will be paid by your health fund.
If your anaesthetist charges above the Medicare Schedule Fee, you will need to pay a “gap” or out of pocket amount toward these fees. Your general dentist or oral surgery specialist may be able to give you an indication of what the gap amount for the anaesthetist will be, or provide details so you can contact your anaesthetist’s rooms.
Before you go to hospital
Before proceeding with a hospital admission, contact your health fund to confirm your level of cover for the procedure, your hospital excess and any other costs you may incur. It’s very important to check with your health fund before proceeding, because not all hospital policies will cover all types of oral and maxillofacial surgery.
If your hospital policy does not cover the type of surgery you require, you should speak to your general dentist or oral surgery specialist about options for public hospital treatment or out-patient treatment. If you proceed with the hospital admission and your policy does not cover the service, then you will be responsible for the full hospital fee (accommodation, theatre charges, etc) plus 25% of the Medicare schedule fee and anything above the schedule fee for the medical (anaesthetist) costs.
To check and upgrade your cover, contact your health insurer.
To obtain quotes and find out your out-of-pocket expenses, contact your health insurer and your Dentist or Oral Surgeon.
For general information about private health insurance and to compare health insurance policies, contact the Private Health Insurance Ombudsman at:
- 1300 737 299
If you have a complaint about your health fund, you may wish to contact the Private Health Insurance Ombudsman on 1300 362 072 or www.ombudsman.gov.au.