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The Dentist San Diego Residents Trust Focuses On Both Big And Small

Dental Trust
For San Diego dentist Dr. Daniel Vinograd, focusing on both the big picture and the small one is essential. This commitment to details and to overall health is why many consider him the best holistic dentist San Diego has.

 

Attention To Detail

For a dentist, details are essential. Fillings must not be too shallow or built up too much. Crowns must fit exactly. Dentures and dental implants must align properly or the patient will experience pain, problems eating and never be completely satisfied.

While a mouth may be generally healthy, a single tooth can need careful attention. Just for a moment, then, all efforts and attention must turn toward restoring that single tooth so that complete health and wholeness is possible. And a biocompatible dentist makes sure everything used for every restoration is okay for usage in the mouth.

 

The Bigger Picture

But a holistic dentist like Dr. Vinograd is concerned with much more than just teeth and oral health. A good holistic dentist understands that oral health and the overall health of the patient are intertwined. The bacteria that decays teeth can also cause heart disease. An acid mouth means an acidic body, and there are health implications from that. An infection in the mouth can spread, and ill health elsewhere in the body can lead to a decline in oral health.

It simply isn’t possible to treat the mouth without considering the whole body. That’s how Dr. Vinograd has established a reputation as the dentist San Diego residents trust above all others: he treats every patient as a whole person, not just a mouth.

In fact, that’s what holistic dentistry is: a focus on a healthy body and its connection to a healthy mouth. Doesn’t that seem like a smart approach to dentistry?

 

Featured post

What’s The Best Toothpaste Available In Stores?

If you want the best toothpaste for your money and for your family’s health, you’ll have to look beyond the most common brands to smaller, less-well-known brands that are more careful what they put in their products.

You can find Sodium Lauryl Sulfate, Carrageean and Sorbitol in some brands. And most brands include Sodium Saccharin, a questionable artificial sweetener that’s the same thing as those pink packets some people once used in their tea or coffee before better alternatives were available.

Worst of all the chemicals found in big-name toothpastes is Sodium Fluoride and the other forms or Fluoride. While this was once considered essential to healthy teeth, there are better choices now that are non-toxic and don’t have the side effects. If you want the best toothpaste available, you want a fluoride-free toothpaste.

So which brands can be trusted? You need to carefully read the label of any product you’re considering, but you can trust some products from Tom’s of Maine, now made by Colgate, Jason and Kiss My Face.

Other brands you may be able to trust are:

  • Dr. Ken’s
  • The Natural Dentist
  • Tea Tree Therapy
  • Vicco
  • Desert Essence
  • Weleda, and
  • Spry.

Reading labels and staying vigilant is as essential when choosing a toothpaste as it is when choosing vegetables, packaged foods and other products for your family. It’s so important to choose the right toothpaste because it goes into your mouth every day, is absorbed through your gums and some of it is inevitably swallowed, especially by children who don’t know any better.

Remember that even trusted makers change their formulas all the time, so a product that’s acceptable one week could be bad for you the next. Remember also that some products from trusted makers are better than others. Not every choice is a fluoride-free toothpaste that deserves to be called the best toothpaste for your precious family.

If you are willing to put in the time, here is a health homemade toothpaste recipe.

Filing Insurance For Oral Appliance Therapy P6

So, it’s going to take a lot of effort from your part to actually get in bed, if you would, with a sleep doctor.  What I would do is look at the area first of all.  See who your initial GPs are.  If you already have a GP, start talking with them for a start.  The other big group is cardiologists.  If you have a cardiologist, start talking with them about what it is you’re interested in doing and what you can do.

Get in on there and get some literature.  Make sure you get all your diligence and your homework so that when you sit down and talk with them, whether it be a lunch or an after-hour, a meeting or something of that nature that they feel very comfortable and confident that you know what it is that you’re talking about what you’re doing.

I happen to be fortunate enough to be in an area where there are a lot sleep doctors.  They are primarily internists who basically have done an initial residency in sleep.  So, that’s where I hook into with those guys, and I’m also tapping in to a lot of cardiologists as well.  So, it’s going to take a lot of networking, but you’ve got to be able to present the fact that you really are confident and know what you’re doing when it comes to sleep in order to get them on board.

 

Matt:

Excellent.  The next question really regards your case fee and courtesy billing.  They’re kind of interested in know what ledge you did that, the particular method, and what, in your experience, is the biggest plus of that facet?

 

Dr. Cress:

Oh, two things.  Let me go with the biggest plus.  What you do that day, you make that day, you take home that day.  It’s really nice.  All your overhead costs and everything is covered, whether it’s a DNA appliance from Arrowhead or it’s one of their oral appliances that you’re using.

If you recall that and this gentleman may not have heard this story ahead of time, we decided early on that if we’re going get into this, we’re not going to be married to insurance companies.  We’re going to present the cases as a case fee.  I’ll tell you what my case fee is.  It’s $3750 whether it’s a DNA appliance for orthodontics or it’s a DNA appliance for OSA or it’s an additional OSA appliance with a SUAD or SomnoDent, it’s $3750.  That is inclusive of everything.

Well the patients that up front, and we do billings to their insurance.  Again, I’ve given checks back for $3750 all the way down to $68, but the patients already know that.  So, it was just a mindset that we had early on, and we’ve learned, for example, the Blue Cross Blue Shield example that I gave where we got no reimbursement all the way up to the gap exclusion.  Those are lessons that we’ve learned, but we were never penalized for it early on.  The patient’s penalized for it, if you would, so to speak, but they’re going to have to pay for treatment either way.

So, again, it was just a mindset.  I learned it from making my wife do it, from the insurance perspective in her psychiatry practice, and it’s just been a win-win situation. It just gets rid of so many headaches and so many issues and stuff associated with trying to collect.

 

Matt:

Excellent.  The next question I’m still trying to paraphrase it as best as possible.  The question starts off with, “It sounds as though you were a traditional dentist initially.  How did you make the transition to sleep dentistry, and how do you present sleep dentistry to your patients that were part of your general practice?”

 

Dr. Cress:

He was absolutely right. I was a general dentist for a period of time, getting burned out, and started snooping around.  Actually, I went to a sleep meeting in, again, San Antonio, the TDA, and I just got totally turned on by the whole area.  So, I couldn’t get enough, and I probably have 300, 400 hours in sleep in the past year with regards to CE courses.

So, that has just kind of transpired and grown and fueled my fire going on with regards to it, but, again, I started and looked at the patient as an overall individual from a health care perspective, not from how many fillings I can do, do they need a crown, what’s my production for the day.  Basically, I focused in on the patient and their overall healthcare and providing their healthcare to them.

I will tell you, every single patient picks up and reads that.  “Oh, he doesn’t really care about this filling or this cavity.  He cares more about my health.  Yes, I do snore.  Yes, I am tired.  Yes, I bark at my kids too much.  My husband and I are having issues,” but really, what is it?  It’s because you’re tired.  You don’t have the cognitive responses that you should have from an individual that’s been well-rested.

So, that basically is what turned me on, what fueled the fire, and how I started at it is the basic Epworth.  Then, again, like I said earlier, if you guys sign up for additional courses in dental sleep medicine, you’ll learn that when we see bruxism and we see tori and we see all this, we think it’s overstress or it’s genetics.  No, there’s research out there that supports the fact that all those are associated with sleep, and then you have the co-morbidities associated with sleep.

When you start talking about people’s overall health, their cardiovascular issues, their diabetes, their impotence to you name it, their weight gain, their weight-associated lost in weight, weight gain and fluctuation, they start getting turn on and they go, “Hey, you’re more than my dentist.  You’re becoming my health care provider.”

 

Matt:
Excellent, and I guess this question is a follow-up to that.   It says, “I’m a dentist who uses a CPAP machine, and I find it to be very complicated process at night.  In your experience, how do patients receive these OSA treatments that you present?”

 

Dr. Cress:

Well, I will tell you this.  If I give them their appliance and they wear it, I go back to them and take their appliance away from them, we’re in Texas.  So, in Texas, we pack guns, they’re probably going to shoot me.  They will never go back to CPAP.  People who we have talked about CPAP with and trying to get them off those appliances into oral appliances have been phenomenal.

Two of the cases I just received, full-mouth cases, I just seated this past week, both of them were CPAP users.  Those CPAP machines have dried out their mouths, have run out their teeth, and I have done full mouth rehabilitation on both of those patients as a result of a side effect from CPAP.  So, that’s a real simple sell.

Even though it’s a huge dollar amount, they’ll do anything about it.  Now, keep in mind, when I do a full mouth rehab on a patient with CPAP, I’ll automatically give them the oral appliance.  It’s very well-received.  I mean in Houston, we have a lot of travelers who do a lot of international traveling, a lot of traveling for CPAP wearers, and the fact that they can just throw that device in their bag and go is, again, an immediate sell.

A lot of those patients, I would say a good 90% of those patients when we talk about insurance benefits to them, they don’t care.  They write a check.  They throw in a credit card.  They could care less.  They want an appliance. If they get something back from medical insurance, great, but they’re so sick of the CPAP device.  I will tell you, 95% to almost 100% of the CPAP wearers have no clue that there’s an alternative to them, have no clue, and we are the alternative, the oral appliance.

 

Matt:

Excellent.  We have three questions remaining.  They’re short ones.  The first one is in regards to the Epworth Sleep Scale.  Can you have your assistant ask those questions, or is it required the doctor be the one doing the questioning?

 

Dr. Cress

No, our hygienists do it.  Our oral hygienists do every one of them, and they do it.  We do it from kids on up. Actually with the younger kids, we ask the parents those questions a little bit.  Those things help because they’re not going to be driving, stopping the car, but we screen every single patient with an Epworth.

 

Matt:

Okay, the next question is a specific ine I guess on billing.  It says, “When billing a Panorex, can you bill medical and dental simultaneously, or is it a one or the other type of deal?”

 

Dr. Cress:

Well, you know, Matt.  That goes back to the whole thing.  I mean, how much do you really want to chase that?  Seriously, and if you get more reimbursement on the dental side that’s fine.  If you get more reimbursement on the medical side, that’s fine, but that takes a lot of effort and time and staff time and cost.  So, the variance between the two isn’t going to be really that great.  You’re basically stepping over the dollars to pick up the pennies.

So, my recommendation on that is do it on medical.  They’re going to want to see it or they’re going to want to know anyway.  Just send it on one side and be done with it.  I personally wouldn’t cross the two for the variance of money.  Then, definitely don’t double bill.  That’s just not right.

 

Matt:
Great.  The last question, then, is, “If you are a fee-for-service, do you still have to submit all necessary documents that the insurances are requesting for the patient’s that are out-of-network? What’s your experience with that?”

 

Dr. Cress:

Yes, absolutely. Here’s the catch:  You ask the patients themselves, “Do you want to see if you have medical coverage for mandibular devices, or do you want to just go ahead and pay for it?” What they’ll do is they’ll go ahead and say, “Yeah, we’ll go ahead and pay for it and see if we got something.”

So, we, again, collect up front, and then, we submit it.  So, we do ask them.  I mean, I have patients that are like, “I don’t care whether you submit or not. I just want the appliance.”  So, if you’re going to do that, we absolutely do, no matter what.  Now, if you don’t have medical coverage, for example, this falls under DME, and if you have the example I gave earlier, if the individual has a deductible on their DME for $5000, what difference does it make?  Go ahead and collect the cash, the $3750.  You give them the paperwork.  They submit to the insurance.  It goes to the deductible.

God forbid they get in some type of accident or something and they need a wheelchair, they’ve met most of their deductible.  So, we do submit no matter what, but we do collect up front for every one of the OSA devices that we do.

 

Matt:

Excellent.  So, that concludes our question and answer period, Dr. Cress. Thank you so much for your time and your expertise on this matter.

Filing Insurance For Oral Appliance Therapy P5

So, if you use these basic simple codes right here, and you have the case fee, whether it’s $2500, $3000, $3500.  Whatever the fee is, if you have your diagnostic information and all the codes associated with your medical billing, you use straight codes here, and you collect up front. Tell the patient you don’t know what the reimbursement is, but, based on the information that you have gathered, they have a percentage back.  Bingo, you’ve collected your total fee.  You submit it.  The checks come back.  They’ll come to you or the patient depending on how it’s in-network or out-of-network.  When they come to you, hand them a reimbursement and be done with it.

Every Thursday afternoon, I usually write anywhere from one to five, six, seven reimbursement checks from the medical side of it, and I’d much rather do that than go through the hassle of continually building each one of the codes.

What’s next?  Filing the paperwork. You’ve got everything from EOBs to electronic filing to status checks for claims to denials and appeals to peer reviews.  I mean it’s exhausting.  Here’s that CMS 1500 if you’re not familiar with.  My software spits that out.

I’m going to run through these really quickly as far as the 1500 because I see we’re getting a little tied up on time, but filling out the form, make sure that you always have the diagnosis codes listed in order of importance. For example, it’s OSA.  Diagnosis of the OSA, that’s going to always provide medical necessity.  Always make sure that you list your CPT codes ranging from the most expensive all the way down.  Make sure you complete all the fields on the forms and make sure you stay inside the lines because they’ll look for any reason to kick you out.

The first 13 boxes is basically patient information; 14 and 15 is when the symptoms occur.  Box 17 is your referring physician, and guess what?  Boxes are going to have sub-boxes so they’re going to want stuff like NPI numbers for your physicians.  For additional notes, CPAP intolerance.  By the way, with the sheet that you get those forms, the directions, you can go online, and they’ll tell you what these boxes are for and what to fill in each one of them.

Box 22 is for Medicaid only.  Box 23 is your pre-authorization number and so forth, dates of service, places of services.  You usually won’t need that one.  You’ll list your CPT codes, your diagnostic codes, charges for each code, list of the units, your NPI number, your TIN number, optional.  If you want to accept your insurance assignment, you say “yes” or “no” there.  Charges for record.  Again, these codes just go on and on and on.  They go in all these boxes.  The total for the claim, that’s really important for you guys to know, and your signature. Then, the last part of it is going to be the location in which your services took place and the name and so forth.

Now, you want answers to all those questions?  Here’s where you get your pen.  Get your sharpener out and get it going.  Here we go. I have a software. I got online with a software company called Nierman Practice Management.  Some of you guys may already have this.  Their update is phenomenal.  It is literally the most customizable software out there.

What’s great about Nierman Practice Management, and that’s the number, 1-800-879-6468.  Rose Nierman owns the company.  She’s phenomenal.  Glenina is great.  The software program is about $4500, and the in-office training is about $1500.  That $1500, to me, outweighs the $4500 that you pay for the software.  Glenina comes in, and she customizes it for you.  She’ll show you a lot of tricks to the trade with regards to filling out the information.

What I love about the Dental Writer is it has a diagnostic and questionnaire reporting exam. Basically what you do is in each one of my computer rooms, I have a flat screen, touch screen computer on the wall, and we pull up the Dental Writer.  Basically, what it is that there’s tabs that you go through.  You click on the tabs, and my assistant reads the part of the exam that I do. I do it with the patient, whether it’s the Epworth or the Mallampati or the tonsils score or this or that, and she just clicks and touches the button and fills in all of it.  When that tab’s completed, she goes to the next tab, and she reads off all the things that I need to do.

Once we go through all the tabs, this software will then go to a diagnostic report.  It automatically writes your SOAP note. It automatically writes your medical necessity, the one that I showed a minute ago.  It automatically writes everything for you. It will also send a “thank you” letter to the referral doctor.  It does everything for you.  It is absolutely the most phenomenal thing I have ever seen.

If there’s components that you don’t one, they can go and delete those for you so you never have to see them again.  If there’s stuff you’re looking for that’s not there, it’s easily customizable.  They’ll show you how to do it yourself, or they’ll do it for you.  It is a great, great way to do it.  It will print out that CMS 1500 form with all those boxes already filled in.  You don’t have to worry about it, and it just fills it in the line so the insurance companies can’t keep track and say, “Sorry, we’re not going to pay for it.” Then, there’s cross coding for medical as well.

I really highly recommended.  I use it.  It’s great.  It’s been a really great work force.  It also keeps track outside of our [46:06], which patients are using OSA and so forth.  Then, the other one is this company out here.  There’s several of them out there.  This is obviously a Texas-based company in San Antonio.  Basically, they don’t get paid unless you get paid.  What they do is they take over the information, and they submit all the claims, make sure everything’s done correctly before they submit it.  Once the reimbursement comes back, you pay them.  For example, if you submit $3000 and you get $2500 back, you owe them $250, but you don’t have to go through all the stuff we went through in order to do some courtesy bill.

Again, dental sleep medicine and craniofacial dentistry has been great for me this past year.  I’ve been happier in dentistry than I ever had in my entire life.  I’ve done more full-mouth rehabilitation cases this year than I ever had in practice in 18 years, looking at people’s airways, opening them up, and getting them back to where they need to be at a better place in life, and I just say enough great things about it.

If you guys have any questions or any comments, we’re going to take a couple of questions, comments, if I’m not mistaken. I’ll be glad to answer them, and here’s my information.  Feel free to call me. I always return phone calls, and I always return e-mails.  They may not be right at that second, but they will usually get done by the end of the day.

Again, thanks Arrowhead for letting me participate in a webinar, and thank you guys for listening to me.  I hope I didn’t carry on too long or talk too fast.  Matt, do we have any questions?

 

Matt:

Thank you very much, Dr. Cress.  I’ll give you a quick second to catch your breath.  I just want to remind all the attendees that we did go over a lot of information.  This PowerPoint will be available if you want it.  The only thing that we ask and the reason that we ask is we don’t want to be accused of spamming our attendees, but if you’d like that, make sure you fill out the question on the survey where it asks if you’d like it e-mailed to you.  We’ll go ahead and take care of that for you.

With that, we’ll go ahead to some of the questions.  We got a number of questions from your presentation, Dr. Cress, and I’ll just try to go into those now.  The first one is from a doctor.  He asks, “In your opinion, do you feel that OSA is going to become a viable means for a dentist to access the more lucrative medical insurance?”

 

Dr. Cress:

Oh my gosh.  You have no clue.  I don’t know who the dentist is, but give them my number.  I’ll give them the financial numbers directly.  It has been phenomenal, and I will tell you.  It’s really a great adjunct to help your patients.  Yeah, I mean, we can do bleaching and we can do all kinds of interesting cosmetic things and so forth, but when you start talking about their overall health and putting them in a better overall position in life, from a mood perspective, it’s just incredible.

So, to answer your question, absolutely yes.  It’s alarming to see the number of memberships who have grown in the American Academy of Dental Sleep Medicine and the American Academy of Craniofacial Pain.  It’s just been leaps and bounds.  The answer to the question is absolutely, 100%.

 

Matt:

Great.  The next question is, this is a doctor asking, “What things do I need to have in place to start offering sleep dentistry, in your opinion?”

 

Dr. Cress:

Well, again, where I actually generated after the TDA meeting in San Antonio, was I came back that Monday, and I printed out the Epworth.  I got it off the internet. I printed up the Epworth.  I put it in my format, and I started asking every single question.  Those individuals that come back that have 8 or greater, I then started looking from a diagnostic standpoint with regards tyou o their work facades or sore eye, their scalped tongues [49:30] and so forth, keeping in mind that that particular lecture is given at Arrowhead for the sleep component of it.  I encourage everyone to sign up for those and learn how to do that.

Then, you start looking beyond Ts and you start seeing things that are very suggestive of OSA. The next step is obviously a sleep study and/or a home sleep study in order to confirm your initial diagnosis.

 

Matt:

Okay.  The next question kind of regards your mentioning sleep doctors or sleep MDs.  The question is, “With OSA and sleep dentistry, what is the type of interaction I’m going to be having with MDs?”

 

Dr. Cress:

Well, here’s the catch.  As everyone knows, it’s very hard for doctors to make money because they have to see so many patients.  So, what you do this doctors going in and out, in and out in order to meet their quotas for the day.

Filing Insurance For Oral Appliance Therapy P4

Aetna considers any of the following diagnostic techniques medically necessary for a member with symptoms suggestive of OSA.  How do you get the suggestive component?  From the Epworth.  You need to have attended a full night of PSG.  Well, good luck on that one.  Most people don’t want to go to a sleep lab and spend the night.

You’ve got a couple of different devices that are available.   You have device II, III, and IV.  Those devices actually measure airflow at at least two different channels.  The one I do is this one.  This is the Watch-PAT you saw a minute ago. It is an unattended home sleep device that monitors three channels.  Mine does pulse oximetry, actigraphy, and peripheral arterial tone.  It also has a little snoring device.  It’s a four-channel.  It’s great.  That will fall under that category as well.

Then, if you happen to do a split night where they do a PSG and find out that they are having apnea and they’re already on CPAP, they do a CPAP and a titration as well.  Then, of course, videos of EEGs and so forth.

Aetna’s members that have AHI greater than or equal to 15 events per hour with a minimum of 30 events or AHI is greater than 15 and less than 15 with a minimum of 10 events.  I mean, come one, really, guys, this is a lot of detail, and this is just Aetna’s requirements.  Most insurances are a little bit heavy, but they’re a little bit different.  So, you’ve got to look for those.

For Aetna, excessive daytime sleepiness has to be documented with an Epworth greater than 10 or MultipleSleep Latency.  Now, let me tell you.  On the Epworth, for the American Academy of Sleep Medicine, theirs is 8 or greater.  I actually dropped mine to 7, but look at Aetna.  This insurance is increasing the Epworth to 10 or greater so they’re excluding a lot of patients who have OSA.

Documented symptoms of impaired cognition, mood disorders, or insomnia.  Documented hypertension, and documented ischemic heart disease.  Documented than 20 episodes of stroke.  Greater than 20 episodes of oxygen desaturation during a full night sleep study.

The bottom line is tell the patient you’re evaluating their limitation when it comes to their insurance.  It is their policy.  Therefore, the outcome of reimbursement on the patient is not for you.  Your job is to work within the guidelines, but you want to obtain the most reimbursement.

Again, I’ve stressed this numerous times and you’ll hear it more in the next 20 minutes that we have:  Case fee, courtesy bill. We have gotten everything from our full feedback on the patient all the way down to $68 from the patient, but if they know they’re going in, they’re okay with it.

The financial responsibility.  The patient is ultimately responsible for the cost of their treatment.  For every case, make sure you have a printed and signed financial agreement and insurance estimate because even an approved pre-authorization is never a guarantee of payment.  You guys know that from the dental insurance perspective.

Again, we want to talk about modifiers really quick.  These are the things that belong behind the codes.  For example, NU is for new equipment, 25 is basically a description of it for significant.  For example, if there’s multiple physicians, 59 basically means it tells the company they’ll pay for the next service as well. On the CM1500 codes, you have the boxes that you put in.  For example, the modifier number 11 means that that particular event took place in the office.  The modifier for 12 means it was a take home test.

So, all of this information is overwhelming.  It’s really kind of just beyond belief to try to get it all together, and, again, I’m going to share with you a way to get around that.

Medical coding for oral appliances.  All medical claims require that the ICD-9 code.  You will use the following codes for oral made appliances: ICD-9 code for obstructive sleep apnea is 327.  That’s the actual diagnosis that you need.   Then, you’ve got the HCPCS code for oral appliances that are made.  That’s the code for it for custom fabricated, adjustable appliances.

Then, here’s all the other codes, the ICD codes, that are needed on your claim forms.  You cannot diagnose diabetes, hypertension, or any of that sort of thing.  This is all from the medical side.  So, if you get a referral from a medical doctor, these are the codes you use for your form in order to submit them. The more diagnostic cods that you can list on a medical claim, the better off you’re going to be in order to prove medical necessity, and you always want to list OSA as the first code, always.

So, coding your office visits.  I think this is really a kind of a joke.  We talked about billing for band aid and aspirin and the cup the aspirin is in.  This is kind of how you guys do that.  Basically, you want to know if your patient’s established or new, and there’s categories for each one of these.  For example, if you have a new patient, there’s codes, for example, for how much time you spend with them.  For example, 99201 is for 10, 99202 is for 20 minutes, 99203 for 30 minutes, 99204 for 40 minutes.  The variation in those is basically the fee, how you’re going to charge.  If you charge $25, $50, $75, and $100, it’s basically on how much time, but look at this really quickly.

If you look at 99203 and 99204, it says, “A detailed history, a detailed exam, and low complexity of medical decision-making.”  For 99204, it’s another 15 minutes.  You’re going to bill a little higher fee, you have comprehensive history, comprehensive exam, and a moderate complexity in medical decision-making.  Guess what?  You better prove that when you send that to an insurance company or else you’re going to get denial on that as well.  That same thing is for the 60 minute one as well.

The same thing applies to different patients.  The same codes, but again, it’s 10 minutes, 20 minutes, 30 minutes, and 40 minutes.  The variance in fees and the variance in what you can get through with regards to how you’re presenting for the medical insurance company.  For example, again, comprehensive history and comprehensive exams.

So, what qualifies you to bill as a consultation instead of an office visit?  When you visit with a doctor.  Again, you can bill for that if you want, but you can case fee it.  Do you really want to spend all that time, energy, and effort in order to get a consultation fee?  That’s totally up to you.

Again, face-to-face with the doc, they have different codes for the time limit that you’re spending, up to 80 minutes, but here’s the deal:  If you have a patient that you have to spend 80 minutes with a referring doctor for OSA, you have no business treating that patient.  Those really need to stay in a hospital study or with highly qualified sleep doctors.

Coding diagnostics.  Let’s look at that for just a second.  These are the codes that you use for the different services that you provide, for the different exams, and so forth.  Each code is different, and you just follow what code you use depending on what it is you’re doing, whether it’s a single view, for example, you use a 300 or a 320 on a whole mouth.  You also want to look out for TMJs and orthodontics and so forth.  These are the codes that you use for that.  If you want to do laryngeal function study, that’s the code you use for that, and that’s the code you use for supplies you use.

So, this ICD code thing is just going on and on and on.  It’s really overwhelming, and I’m sure you guys are ready to disconnect and hang up, but hang in there with me for a minute because I’m going to show you a way to get around this.  You’ve got additional codes for additional appliance repair and anything else you need to do.

Again, the Epworth Sleepiness Scale is totally required 100% with regards to any of the issues associated with the patient.  I do Mallampati Scores.  I you guys haven’t done it, it’s really simple. Ask the patient to say, “Ah”.  On the “ah” stick their tongue out, look at the back of their throat.  Figure out which one they are.  Mark down the Mallampati score and submit that with your insurance claim.  Home Sleep Study Test.  We talked about that as well.  The actual diagnostic report that comes out with this, submit that with the report as well.

Then, the fee range.  Talk about that for just a minute.   Look at this chart.  This is what I was talking about with the band aid and aspirin component.   You have a category of new patient, established patient, and consultation.  Under each one of those, you have 10, 20, 30, 45 minutes and so forth divided based upon the insurance or the amount you’re going to charge based on that particular individual.

If you really want to spend the time, energy, and effort to keep track of all of that and find out exactly where you are, knock yourself out.  It’s much easier to do a case fee and be inclusive and have the case fee set and then submit, for example, the 99203 for every new patient, 30 minutes on all of them because you’re going to get at least that information up there.  You’re going to spend at least 20 to 30 minutes with them.  So, just fill it in as a case fee.  It works so much easier.  If you want to break all of that down, more power to you.

Here’s the case fees basically for some of the stuff that we do:  Pharyngometer, rhino, the pano, jaw joint x-ray, and the appliance.  There you go.  These fees are ranges.  Every area is a little different, and you can put it all together.  Let’s put all of this together really quick.

Example billing. We’re going to look at visit, service, codes, modifiers, charge.  This is an initial consultation for an office visit.  There’s your code, your modifier, and your charge.  Here’s a panoramic x-ray, your code, your modifier, and your charge. Photographs of the airway, your code and your charge

Impressions and bite.  Your established patient office visit, your code and your charge.  Cone beam is the same as well. The actual appliance was a DNA appliance or a mandibular appliance plant.  Again, there’s your code, your E0486 and your modifier in NU for new and your fee.  Your fee can vary, whatever it is.  It’s just an example.

Then, you want to deliver.  We’ll tell you this.  Fitting and adjustment is included with that actual fee for the appliance.  So, you can’t double bill for that.  Then, you have your follow-up fees as well.  There you go.  There’s your total.

Filing Insurance For Oral Appliance Therapy P3

Then, we have these wonderful things called HCPCS.  Then everything that didn’t fall under Level 1 falls under Level 2, and if we forgot anything, we’re going to put in in the HCPCS Code.  Unfortunately, one of the things that we’re doing, which is the oral appliance, falls under the durable medical equipment, prosthetics, orthotics, and supplies, and that goes up there.  It’s five characters with one alpha in the front.  For example, with the oral appliances, it’s E0486.

Some additional things that you need to know, some of the wonderful modifiers, in addition to the CPT codes.  It shows the insurance companies how these circumstances that may or may not need to be known with regards to the claim.  When the medical claim comes through, you know what they are going to do.  They’re going to reject it, but if you resubmit it from an appeal perspective and you have modifiers there, it gives them, “Hey, look at this.”  For example, there’s unusual circumstances.  There’s multiple physicians.

All you guys know about EOBs, explanation of benefits. I don’t really need to spend much time on that because you do it on the dental side.  Durable medical equipment, again, that’s the where the appliance falls in.  Let’s look at that for a little bit more detail.  Basically, insurance companies define DME as something that can withstand repeated use.  It’s an appliance or anything in that nature than can withstand repeated use.   It is primarily and customarily used to serve a medical purpose.  Generally, it is not useful to a person in the absence of an illness or an injury, and it’s excludes all items that are disposable.

Let me clarify something a little about DME. DME is a subcategory of every single policy.  Let me give you an example.  If your medical deductible is $1000, guess what?  There’s going to be a deductible limit on DME.  So, all these deductible limits are relatively high.  They’re $2000, $3000.  Sometimes, we’ve even seen them as high as $5000, $7000 just in the DME side, forget the medical side.  So, when you get that information, that’s really a green light to collect cash and go forward because that’s going to be net towards your deductible.  Anyway, they’ve got to pay that out of pocket anyway.  So, there you go.  It’s really a win-win situation.

So, DME.  Make sure you look at that net specifically if the patient met the deductibles on the DME and what is their deductible limit on the DME.  Again, we need to provide medical necessity, and very important on how we do that is your documentation.  Every claim that must be backed up by accurate, complete documentation because the patient’s medical record is a legal document.  So, think about it like you’re going to court and you’re trying to prove in order to get the money that you have earned the patient has a medical necessity for an oral appliance.

The SOAP note configuration is what insurance companies love.  Some of you guys have probably done SOAP notes in school, and if you do SOAP notes in your practice, that’s great.  Those are the best format to use for medical documentation, and basically, it’s subjective, objective, assessment, and plan.  So, let’s talk about that real quickly for just a second.

Subjective is basically the chief complaint.  Patient was seen in the office today choking and gasping at night and would like to find out more about an oral appliance.  That’s basically the chief complaint.  Then, you have the objective component.  Symptoms that can be measured, heard, touched, smelled, seen, and also the diagnostic results, weight, height, neck size.

The other thing is the assessment.  Basically, what is the diagnosis?  Possible sleep breathing disorder. Then, the plan.  What is the treatment plan?  You go for PSG.  Do they need to be referred to a GP or a sleep doc? That’s what plan is.  Basically, that’s how a SOAP note is designed.

So, let’s look at the process.  First, you want call and check the patient’s benefits.  Then, create reimbursement estimate for the patient, and again, if we do a case fee, it works really, really well based upon having that limit set out there.  You want to gather records you will need to file the claim.  For example, sleep study reports, medical histories, etc.  Then, you want to submit the pre-authorization for all services if it is required.

Again, Blue Cross Blue Shield, you have no way around it.  So, if you call, for example, Cigna or Aetna, ask them specifically, “Is pre-authorization required?”  They’re not going to tell you that, and you submit, you’ve lost it.  You want to submit a claim for the initial visit, diagnostics, others, and so forth.  You want to submit the actual claim for the oral appliance itself.

You guys have probably heard stories or might have been exposed to it, but when you go to a hospital and they charge for a band aid, they charge for an aspirin, they charge for the cup the aspirin is in, it’s all in your bill and your bill is 30 pages long for a 20-minute stay, the reason they do that is because they know the insurance companies are going to create or discount that quite deeply.

You guys can do that as well, and we’ll show you all the different ways you can add to this in order to build the fee up large enough so that you actually get compensated a fare rate.  Again, we prepackage and do a case fee for one set number, and everything is included in it.  It’s so much easier, but if you want to go down that track and you want to go and submit for every single thing you do in order to get the limit, knock yourself out.  Go for it, and you’ll see how exhausting it is.  Then, you’ll submit the claims for follow-up visits and so forth.

Let’s talk about submitting a claim.  You want to require documents to obtain reimbursement.  You want a copy of the PSH with diagnosis of OSA.  So, the appliance is not going to be covered if the diagnosis is primary snoring.  If you’re going to do primary snoring in your office, go ahead and sit in one of the stabilizing devices or one of those devices that they put in.  Just do an office visit or an office fee for it, and then be done with it.  You’re not going to get any coverage because of snoring.

Then, the CMS 1500 health claim form.  Those can be purchase from the AMA and many office supply stores.  One of the lifelines I’m going to give you, one of the software we use in the office actually generates those forms with all the information already filled out.  It’s really cool.

They need a letter of medical necessity.  This is really a great, great edge to help facilitate reimbursement from insurance companies if you get this form.  PAT screener, for example, or sleep study or anything of that nature.  This, number five, is absolutely the golden rule:  If you get a referral from a sleep doctor or a physician that the patient has CPAP-intolerant and would like oral appliance, have them write out, on a prescription pad, oral appliance and “Rx”.  Submit that with your claim.  The patient has already established a relationship with that ongoing physician, so they’re already going to be knowing that they are seeing Dr. X for sleep apnea.  They’ve already had the CPAP machine, and when that Rx from the doctor, it really helps facilitate that reimbursement.

Then, there are letters to describe symptoms, diagnosis, and appliance and treatment again from the dental sleep professional and a point of contact within the office for both patients and the insurance company.

Again, medical necessity.  I can’t stress how important is a letter of medical necessity.  Let me just show you a little outline letter.  Don’t try to freak out about all this, but this is actually generated from the software that I have.  I’ll share it with you at the end, and it fills out all the patient information and data.  Basically, it says this patient has fitted with a CPAP machine.  The patient is unable to tolerate the CPAP machine, and it goes in and says, “The exhibits the following signs and symptoms and therefore needs and oral appliance.”  This is a letter of medical necessity.

The second one is called the sample affidavit.  Basically the patient is saying, “I have attempted to use CPAP tom manage my sleep-related breathing disorder and find it intolerable to use based on the following reasons.”  They check that.  They sign it.  It’s a valid affidavit.  Those guys are required, as well, to get some reimbursement from them.

If you don’t already do an Epworth Sleepiness Scale screen form for all your patients, I highly encourage it.  I will tell you that all of my patients that I have gotten with the exception of a handful that I have gotten from referrals have been in my office.  How do we do that?  Starting from Monday morning, every patient should get the Epworth Sleepiness Scale.  It should take only take a few seconds to ask these questions and fill it out.  If it is 8 or better, then it is suggestive that they have OSA.  So, you can Google this and you can create your own form or letterhead, but the information is on there.  Anyway, all insurance companies require an Epworth Sleepiness Scale form filled out so you might as well go ahead and do it and be done there.

We have these great little guys.  They’re called Watch-PAT.  They are used for home sleep study.  So, if the Epworth Sleepiness Scale comes back 8 or greater, we talk to the patient about letting us program one of these for them and let them take it home and sleep with them.  Basically, it gives us all the information that we need.  It’s a great screening tool for sleep apnea, and, again, that report we actually submit with the insurance claim.

Now, there’s a catch to it.  That has to be signed by an MD.  Watch-PAT, Itamark manufactured that has actually a staff that will interpret the study for you and sign off on it, or if you have a physician that you are working with from the sleep perspective, they can sign off on that as well.  Keep in mind, MDs diagnose, dentists treat. So, we’re not allowed to diagnose although, I think, in the near future, that’s going to change.

This is absolutely the golden key right here.  If you can get a prescription from the doctor asking for an oral appliance, I can’t tell you how much weight that really carries.

So, insurance wants to know what is clinically significant for OSA.  Let’s talk about that for a second.  AHI is greater than 5 and less than 15 for at least one of the following is met:  Excessive daytime sleepiness documented symptoms of impaired cognition, mood disorders, or insomnia; documented hypertension; documented ischemic heart disease; documented history of stroke; or greater than 20 episodes of oxygen desaturation during a full night sleep study. That’s what they consider clinically significant.

Now, let’s take that one step further, and I’m only using Aetna as an example.  Every single insurance company is different.  I’m sure all of you guys are exhausted already just listening to the information I’ve given you with regards to trying to get reimbursement for medical insurances.  That’s why I feel it’s very important to do case fee and courtesy bill for the patients.

Filing Insurance For Oral Appliance Therapy P2

Let’s look at Medicare for just a quick, few minutes.  I want to run through this a little bit.  Some of you guys may have already been a little exposed to Medicare just from personal experience or a family member, but Medicare has several parts, Parts A, B, C, D.  A is for hospital.  B is for the supplementary insurance.  C is for Medicare Advantage, and D is for prescriptions.

The Medicare DME handles the durable medical equipment.  So, when we talk about oral appliances and you’re looking at medical reimbursement, you’re looking at DME, durable medical equipment.  You will need to contract with Medicare Part B and Medicare DME for your jurisdiction, which is the area which you’re located, in order to file for the reimbursement, and we’ll talk about how that’s broken down.

In Part B and Medicare, your jurisdiction, depending on which one it is, wherever you are.  For example, if you’re in Florida, you’re Jurisdiction 9.  What’s interesting about Medicare is when Medicare uses the insurance industry standards.  For example, if Medicare in Florida says, “We’re only going to reimburse you the implants at $1000,” almost all insurance companies follow suit for example, but if you’re in California, let’s say, that reimbursement level may be $1500.

So, that’s why they categorize you and put you in jurisdictions based upon where your overall demographics are and what’s basically financially acceptable.  So, if a procedure is done in Florida for a certain fee, that same code will be done different in California because of the jurisdictions.

Durable Medical Equipment here.  Again, the same thing.  They have jurisdictions based upon A, B, C, and D.  Depending what state you are depends on what jurisdiction you fall under.  So, what I say is just say “No” to Medicare.  If per chance, you do want to do it, you need to go ahead and contact them and get their rules and regulations and follow along. If you decide not to, you have to opt out of Medicare.

Now, that website down there is very important.  You don’t need to write that down because I’ll give it to you later, but if you’re going to opt out of Medicare you need to let them know.  If you don’t wish to participate, you need to opt out every two years.  If you do not opt out of Medicare, then you’re in, and you have to accept Medicare patients.  So, we opted out early on, and we just follow that two year rule when it comes up for us to opt out again we’ll do that as well.  If you want to accept Medicare, that’s fine. Go ahead and go to that website.  Get typed into their provider relations services, and they’ll get you set up in a way you can go.

Let’s talk about in-network and out-of-network benefits.  You guys are probably used to that as well because in dentistry you kind of deal with that.  In-network, patient pays deductible and co-pays.  Insurance benefits paid to the provider, and they provide a fee schedule for you.  If you’re out-of-network, patients pay deductibles and co-pays.  Insurance benefits pays for the patient, and there is no provided fee schedule at all.

So, if you’re in-network, you will have a pre-negotiated fee schedule for the services.  If you’re out-of-network, you can do whatever you want, and guess what?  We’ve elected to do the case fee and the courtesy bill so we’re out-of-network.  We’re in control of our fees and what we want to do with regards to that.

So, you’re either in or you’re out.   So, all providers have the choice of participating, contracting with an insurance company.  You’re not really forced to.  Let me just give you a heads up.  For example, if you are a Cigna provider for the dental side, that does not make you a provider for the medical side.  So, when you call a patient and the patient of yours is a Cigna patient from the dental perspective or the dental side and they come to you with Cigna insurance, do not make that assumption that you fall under that category.

When you call to verify the benefits do not make that assumption because you will get bitted in the tail end with regards to that.  They’ll tell you, “You’re on dental?  That means you’re already on medical.”   You’ll think, “Okay.”  You’ll hang up the phone, submit it.  Guess what?  You’ll get no reimbursement because you’re not on the medical side even though you may be on the dental side.  If you’re not participating with an insurance company, you are not required to file a claim.  It is the patient’s responsibility, and that’s really a nice little thing to go with.

Some in-network advantages.  The insurance companies will distribute a booklet to their customers listing all providers.  This is a cool concept if you want to think of it from a logistic and financial perspective.  They’re basically doing some marketing for you through the network.  Many patients will choose to stay in-network knowing it will most likely mean less out of pocket money, but it’s also less expensive.  Let me give you an example.

Let’s say you paid $1000 for the appliance, and if you’re negotiated fee is only $800.  Look at it this way, the other $200 that you’re not getting for being in-network is really going towards marketing because all you guys know you will pick up the phone and ask, “How did you hear about us?”  “Through my insurance.”  So, think about that for a little bit.  Don’t get turned off by being in-network, but take the discrepancy number there and apply that to marketing in your mind.  You may need to pay just a little bit.

Payment is made directly to you instead of the patient, and some insurance companies do now allow payments to providers who are not in-network.  So, the patient is responsible for everything, and that can be kind of cool.  It also speeds up claims.

Then, some disadvantages.  By becoming in-network, you’re accepting the rules and guidelines of the insurance company.  Now, on the medical side, if you think the dental side is bad as far as rules and regulations, we’re going to go to an example a little bit, and you’ll see how diligent they are in all the hoops and all the agility that you have to go through in order to jump through the hoops and jump through the rails in order to get reimbursed.  It’s pretty significant.

If you don’t follow the rule and guidelines, guess what, guys?  No money.  You can’t charge a patient.  Your pre-negotiated fee schedule means it will be probably less than what you normally charge, but then, again, take the variance in the fee to go towards what we call your marketing department.  All providers have the choice of participating in contract with insurance companies or not, and if you’re not participating in an insurance company, you’re not required to file a claim.  Again, that’s really nice as well.

Again, contracting with insurance companies means you’re getting in bed with the devil.  Let’s talk about that.  Let’s see how we do that.  First of all, you’ve got to gather all of your information, your credentials, your licensing, and everything that you can possibly do in order to submit applications with regards to trying to become a provider.

Step two, you call the company.  Most insurance companies have a specific application process that they’ll send you or e-mail you or tell you to go online.  Some of them often have contact people, liaisons, within their company that help through the process and make it a lot easier.

Step three, check back.  As soon as you have sent something, that doesn’t usually mean they’ll get it in.  You all know how that goes.  That game is played on the dental side.  So, it’s the same thing on the medical side.  They really want you to provide.  They usually give it about a month then check back and see how they’re doing.

Here’s the problem that we have found snooping around, wanting to become providers on the medical side:  Dentists have a little bit more difficult time contracting with insurance companies.  They’ll be limited to in-network participation for oral surgeons and physicians, but for dentists, they’re not really too excited about that.  For most insurance companies, the process takes anywhere from three to six months depending on how hungry insurance companies are to get you on the provider list.

We talked a little bout hoops and agility and jumping the hoops.  Here’s a neat little thing.  When you call for verification, of benefits, you need to find out if they have a gap exclusion exception.  You’re wondering, “What the heck is that?”  Here we go.  It basically means that your patients will receive their in-network benefits even though you are an out-of-network provider.  Now, here’s how that plays out.

There’s two ways to do that.  One is that there’s no providers near the patient, usually 20 to 30 miles, who are in-network who can provide the services or if a physician who’s in the in-network with the patient’s insurance refers directly to you for treatment.  Let me give you an example.

You’re going to provide a service to a patient who as Aetna, and they give you “yes,” and everything is good.  If you don’t ask for the gap exclusion in your provider’s service, they come out and say, “Guess what?  Dr. Smith, the oral surgeon across the street from you in in our provider list.”  You’re not going to get reimbursed. Even though Dr. Smith may not be doing oral appliances for sleep, you’re not going to get reimbursed.  You need to ask specifically if there’s a gap exclusion or exception, and if you’re not, you’re good to go.  If there is, you need to find out who the next closest person is, and the insurance companies will give that to you.  You need to discuss that with your patient so that they don’t get burned either as well.

It is best to request this prior to treatment or pre-authorization when you are checking.  Once you’ve determined that the oral appliance is a covered benefit, then pre-authorization is usually required.  Let me just give you a heads up.  On Blue Cross Blue Shield, if you do not get a pre-authorization from Blue Cross Blue Shield, you will not get a penny.  It doesn’t matter if they have a $100,000 coverage for oral appliances.  You won’t see a dime of it.  You have to get pre-authorization.

So, some insurance companies are very picky about that.  We know, for a fact, that early on, like the second or third oral appliance we did with Blue Cross Blue Shield, and the patient got burned.  He was very nice about it, and he paid up front.  He just wasn’t going to get any type or reimbursement.  So, be careful about that.

If they do, and if they don’t have a provider who is in-network for oral appliances, the company will honor the patient’s in-network benefits.  If the patient is eligible for the gap exclusion, make sure you write that reference number down so that when you put it on the CMS form that you said a gap exclusion is there.  So, they won’t come back and say, “Sorry, we didn’t say,” or “You didn’t ask,” because you have it in writing.  You have the extra credit.

Let’s talk about terms that we need to know.  What’s wonderful about medical insurance is we have a whole set of nomenclature, new codes to learn.  The ICD-9 Code are International Classification of Diseases Diagnostic Codes.  So, for example, the diagnostic code for OSA is 327.23.  Now, don’t write that down because you can get these online.  You can get it from a book. You can get is just from a presentation.  Don’t burn your lead out doing it.

The other one is the CPT Code.  Those are Current Procedural Codes.  I love it because they have two levels.  Level 1 is basically a 5-digit numerical code.  If you’re doing pulse oximetry it’s 94762, and guess what?  There’s always going to be a modifier at the back of it.  In other words, there’s going to be an additional digit or letter, and that basically clarifies the description, whether it was done in the office or whether it was done at home.

Filing Insurance For Oral Appliance Therapy

see the video: http://vimeo.com/28067585

Matt:

Today’s topic is “Filing for Medical Insurance for Oral Appliance Therapy”.  We’re very excited to have all our attendees here as well as our presenter Dr. Sam Cress from Sugar Land, Texas.  He’ll be discussing this important topic and help you see the benefits of adding this to your practice.  Dr. Cress, the time is yours.

 

Dr. Cress:

Good morning.  Thanks, everybody for attending. I’d like to take this opportunity to thank Arrowhead.  I will tell you I’ve been with Arrowhead for about 18 years, and I’ve had great success with them.  I did a webinar series the last couple of months that has been presented that have been phenomenal.  So, I encourage everyone who’s listening in the future to listen to the webinars.  It’s a great, great opportunity for your staff to listen in and get some continuing education, and it’s very economical, just gathering around the office.  Tap into their webinars.  It’s really awesome.

Let me tell you about who I am.  I am a general dentist in Sugar Land, Texas, which is a suburb of Houston, and I have been in practice for about 18 years. In the past year, year and a half, I really have gotten turned on to dental sleep medicine, craniofacial dentistry and dental sleep medicine.  It’s been a phenomenal ride.

I just completed my residency in dental sleep in Tuft this past spring, and I am eligible for certification.  So, I am working on all my patient requirements and criteria in order to present and take the boards in June.  Then, I’ll become a diplomat in dental sleep medicine.  I just highly encourage anyone who’s interested in that area, field of dentistry to really pursue it.  It’s been a great ride.  It’s been exciting and so forth.

Today’s topic that we’re going to be talking about is “Filing for Medical Insurance for Oral Appliance Therapy for Obstructive Sleep Apnea”.  Now, I’m going to go out on a limb a little bit and make the assumption that you guys are already doing some type of dental sleep medicine or at least know a little bit about sleep medicine because a lot of the terms I’m going to be using, for example AHI, this is not really the format to discuss what those sorts of things are.

I would encourage you to contact Arrowhead and sign up for one of their sleep seminars, and, again, I’ll be presenting there as well.  We can go into details about sleep and the different indices and criteria for sleep.  We’re just going to be focusing on getting reimbursed.  It’s great to have all this knowledge and share this knowledge and be able to integrate this into your practice, but if you don’t get compensated for it, it really is kind of a moot point.  So, I’m just going to make an assumption.

Now, let me tell you a little quick story about insurance in general.  My wife is a psychiatrist, and we own our own building.  I’m on the first floor, and she’s on the second.  When we built the building, she was director of the mood disorder clinic in Baylor. When she was coming out, the first thing she said was, “How do I get on these insurance plans?”

I told her.  I said, “Listen, here’s the deal:  If you sign up for insurance plans, I’m going to file for divorce.”  That was 18 plus years ago.  We’ve been married for 22 years.  She did not sign up for any insurances at all.  She came in, and within 90 days, she was solid-booked.  So, today, if you call her office to see her as a new patient, you’re first available appointment is in October.

The reason I shared that information with you is because I encouraged her and really did support her in the fact that she does not need to be married or handed down, handcuffed to insurances.  When we did the dental sleep medicine component of our practice this past fall, the lady who’s been working with me on insurances for a long time, she and I went up to a presentation in Dallas.  We talked all the way to Dallas and all the way back, and we committed that we would not be married to insurances.

So, what we decided to do for sleep apnea was to collect up front, do a case-fee presentation, everything conclusive, collect up front, and courtesy bill for the patient.  It’s been incredibly successful for us.  We’ve had no issues whatsoever, but we’ve learned a lot of things about medical insurance and how different they are from dental insurance through the process.

So, my number one encouragement is for you to get that mindset that hey, I need to do a case-fee courtesy bill and collect the money up front and let the insurance ride, if you will.  You’ll see when I start presenting a lot of things to you, you’re going to get a little overwhelmed, and probably in about 10 or 15 minutes, you’re going to start tuning out.  You’ll see why when you see the volume of information that you have to do in order to get medical reimbursements for insurances.

So, anyway, get a pen and paper.  I’m going to throw you a lifeline at the very end of this presentation with some information that, to me, is very crucial to put all this together for you and kind of helps you through the process.  So, make sure you have a pencil and pen ready.  So, let’s get going here.

So, basically, when we file for dental sleep medicine, reimbursement for OSA.  You can do a couple of things.  First of all, you can bill on behalf of your patients, which is a nice way to do it.  It’s kind of the internal marketing procedure as well.  You can assist your patients to bill themselves.  Now, here’s the problem with that.  We already have a big, hardship trying to understand medical insurances and dental insurances as it is, but if you can imagine that turning over to the patients, they will be in your office everyday with tons of questions.  So, you can do that, but that’s going to be very challenging and very time-consuming on your part.

You can easily outsource your medical billing to companies.  There are several companies that are out there from coast-to-coast in your area that will actually do a medical bill for you.  They’ll submit everything for you, and they take a percentage of what they collect.  Then, you do fee-for-service only, which is what we do.  We do fee-for-service, and we do courtesy bill.

Here’s the key to any type of medical insurance when you get ready to bill.  I’ll look at it as trying to be the old Perry Mason if you would, trying to be the attorney.  You have to prove to medical insurances that there’s medical necessity.  They’re not going to hand those checks over very easily.  So, here’s how we’re going to do this.

First of all, understand medical insurances.  Working with insurance companies to obtain information about patient’s benefits.  You guys probably already do this in your practices, especially with dental insurances.  The only thing difference with medical insurances and dental insurances is dental insurance will give you no information except the patient is within or with no network.  So, they’re not going give you specific fees.

With medical insurances, we have learned are a little bit more open and will communicate with you a little bit more as far as the information in order to determine the benefits for their patients, but you need to learn to interpret each patient’s insurance policy because they’re all different.  Every single company has multiple policies and multiple sub-policies within that.

You also have to know a whole new type of nomenclature which is the Diagnosis Codes, ICD-9 codes, Procedural and DME codes as well as CPT and HCPCS codes and modifiers.  Then you have to fill out the CMS1500 form.  Now, we’ll talk about this in a little bit and how to do that.  Then, you’re going to submit all the documents that go with it. Now, guess what?  You’ve got to do the follow-ups and appeals as well.

Now, let’s look at the different types of insurances that are available and some of these guys you already know.  You have the PPOs, which are the in-network of physicians or hospitals that provide services.  The patients can choose to go out or in.  It depends on how much they want do and if they want to stick with their providers.

Then, you have Blue Cross Blue Shield.  Now, they’re a little bit of a tricky plan.  You may not have experiences on your personal side or with your patients.  They have the fully insured plans which are purchased and managed through Blue Cross Blue Shield.  Then, they have the self-funded which are underwritten by the company, but they’re managed by Blue Cross Blue Shield.

Then, we all know about HMOs.  I will tell you this.  Every patient that comes in with an HMO and you want to do oral therapy for them, you really need to find someone in their network to do that if you’re not a provider because you will get absolutely zero reimbursement.  The patient will get zero reimbursement.  Now, if the patient is on HMO and wants to pay cash up front, that’s okay as well.

Point of Service Plan.  The benefits are determined when the patient decides whether they want to be out-of-network or not, and, of course, our absolute favorite are the indemnity.  Now, those are very few and far between.  I’ve been practicing for 18 years, and I’ve only had one patient who has full indemnity.  If he came in today and did a full-mouth reconstruction, his insurance pays 100%.  He’s a little mucky-muck high-end individual when it comes, but those are very few and far in between.

Now, I’m not really sure what the demographics are, but for those individuals that are in the military, there are military insurances as well.  Now, where I’m located, we don’t have military bases, but basically, there’s TRICARE or TRICARE for life.  That’s for active duty and retired military personnel.  There’s two different kinds:  There’s TRICARE Prime, and that’s for all active duty.  There’s no co-pays and no deductibles. They can go to a non-military provider, but they need a referral in order to do that.  Then, there’s TRICARE Standard, which you’re probably going to see a little bit more of, and that’s fee-for-services.  Co-pays, deductibles apply.  Referrals are required, it’s much easier for that.

Let’s now talk about sleep apnea for just a second and prevalence with age, and it plays a very important role when it comes to insurance.  Now, there’s the orthodontist on the panel on the discussion here.  I’m not going to try to offend them in any way, but orthodontists, we in dentistry can create a lot of apnics by removing bicuspids, moving everything back, shutting everything down.

As we become older, and I can say it that way because I’m one of those patients, we see a little bit more higher prevalence of sleep apnea at this age.  We also see a lot of dentition and a lot of other things as well plus as the generation is getting older, we are learning more and more about apnea and sleep apnea.  So, you’re going to see a lot more prevalence with individuals with sleep apnea in the older age.

So, guess what?  We have to look at Medicare.  Now, Medicare is for 65+.  Now, I will tell you there is a gentleman who is very, very successful in Idaho, a colleague, a friend of mine who probably does about 80% Medicare for oral implants and sleep apnea.  The reason he’s so successful is because he understands and really gets in bed with Medicare and really knows how to work the system based on the rules.  They have a very set standard of rules, and you have to follow them to the tee for reimbursement.

LEVERAGING NATIONAL HEALTH REFORM TO REDUCE RECIDIVISM AND BUILD RECOVERY P8

Then, we have some key stakeholders that have some different goals and incentives, and one of the previous questions brought up to participate and also role.  So, just a quick review of those.  For behavioral health and medical care providers, expanding capacity, integrating primary care and specialty care, integrating community care with justice-based services, expanding their own capacity to enroll clients in Medicaid and insurance because certainly there are going to people who come not enrolled, improving treatment through the use of evidence-based practices, and then cultivating partnerships with new stakeholders.

County government officials, we were talking about their incentives to minimize cost and litigation risk is related to health care issues in jails.  Their option is to maximize diversion and effective re-entry services to reduce future demands for incarceration and reduce current demands for incarceration.  That’s the diversion side. It important I think for them to assess the potential risks and benefits.  They have the capacity to convene local planning processes to develop local action plans and also to help work the questions of the governmental food chain to bring the Medicaid folks to the table, to bring the insurance folks to the table, to bring the bring the Department of Public Health folks to the table, and to investigate reallocation of funding from county corrections to community health services if that’s something they want to pursue.

For state Medicaid directors, the criminal justice system presents a great opportunity to enroll a lot of people in a timely and efficient manner.  It does require some modification, possibly of how they’re thinking about doing it right now, but the numbers of people in the criminal justice system who are going to be a part of the newly eligible group are going to be so large that you’re going to get their attention if you bring the numbers to them.

So, collaborating with criminal justice and behavioral health and medical treatment providers to reduce coverage barriers, expediting enrollment, and also to facilitate strategic planning of the capacity expansion and again with special attention to rural or underserved communities.

State insurance directors are going to be operating health insurance exchanges, and there are going to be people most likely on probation who are, through family income or some job they hold, may not be eligible, may not be below that 133% poverty level but will be eligible for insurance subsidy through the exchange.  So, we want there to be continuity of access, continuity of coverage plans so, for example, one of my clients who, today, makes no legitimate income but gets a job once they’re in recovery, I don’t want them to be suddenly priced out of ongoing substance abuse care and our services.

So, that’s the value of establishing this continuity from my perspective.  I think from the criminal justice system perspective it’s just that writ across many hundreds of thousands of people want.  Also, proper integration of this population into managed care.

For criminal justice officials in jails, corrections, probation, and parole, partnering in systems integration efforts is really important, maximizing Medicaid and insurance enrollment is important, and partnering in diversion efforts will also make a big difference.

I don’t know if we have any judges on the phone, but judges, in particular, have a very strong role in convening groups of different stakeholders to try to bring this conversation into focus.  We work a lot with our judges to try to do this thing. They create a neutral framework, and they create some clarity about what the stakes are what’s needed. It can be very helpful.  So, we certainly encourage them to be involved.

That was the slide in the presentation.  Here are some resources that you may want to take a look at.  The links may not appear so well on the slide, but you’ll be able to see them more clearly when the presentation is available.

There was a national conference, the Community-oriented Correctional Health Services Conference Coaches.  We submitted a paper for that conference.  It was sponsored by the Robert Wood Foundation, and all of those conference papers may be of some interest to you.  There was a presentation form the Substance Abuse and Mental Health Services Administration thinking about this from the provider and treatment center perspective that was just given in July.  It was excellent. I encourage you to look at that.  The Council for State Governments also has a frequently asked questions document on health care reform.

So, those are the three things I wanted to suggest for folks who want to dig a little deeper into this.  Certainly, I’m available for e-mail and phone if want to talk further about this.  We’re doing a lot of national and local advocacy planning, and the whole thing’s unfolding day by day.  So, it’s a very interesting time.

So, Monica, we have a few more minutes if people want to ask more question.

 

Monica:

Okay, I have a question here from Herb.  Let me put unmute your line.  I can’t unmute his line.  Let me unmute Colleen’s line.  Okay, Colleen?

 

Colleen:

Can you hear me?

 

Monica:

Yeah.

 

Colleen:

Yes.  Hello, my question has to do with, I’m aware of the shortage of clinicians especially chemical dependency professionals, but are there any incentives coming down the pike with regards to raising the rate of pay or anything like that?  I know quite a lot of people who would like to be in the field, but they’ve done the research to find out the rates of pay overtime and have really chosen not to go into the field because of it.  Is there anything that we’re looking at as far as that goes?

 

Maureen:

Well, that is certainly a persistent problem in our field, and it’s trying to take grant dollars and make them stretch as far as you possibly can, I think, is one of the mechanisms by which pay rates for services and pay rates for people have been suppressed in that one.  So, I think that the natural market mechanism of demand will have an impact or raising prices in the more capitalist way.  The other way this will get worked out in terms of rates for services is it’s going to be all negotiated at the state level.  So, I would encourage you or through your provider organization to really take a look at how you all can influence that conversation.

We’re not quite there yet, but it’s a good time to start asking questions about when and where those decisions are going to be made and how to influence them.

 

Colleen:

Okay.  It just seems that some of these folks in this planet are being taken care of by some of those who get some of the lower rates of pay in the human services industry.  So, just curious about that.

 

Maureen:

Yeah.  I have about 299 colleagues in this agency who couldn’t agree with you more.

 

Colleen:

Yeah.  Thank you for that.

 

Monica:

We’ll go to our last question, and let’s see.  Herb?

 

Herb:

Yeah, hi.  Thanks for taking my call.  Do you hear my now?  Okay.  I guess I was just wondering and I left a couple of times.  I had a couple of things I had to attend to.  So, forgive me if you covered this, but is there any return on investment information on any of this in terms of primary prevention or prevention in terms of insuring that our clients and their family as well might be in better shape healthwise.

 

Maureen:

Yes.

 

Herb:

What I’m thinking is this.  For instance, I walk outside, and there’s always a handful or more of our clients smoking cigarettes.  We’re all paying for this high price, and I’m wondering is there anything down to that specificity on programs that might work and what the return on investment might be, something like that or other specific ways.

 

Maureen:

Well, the work that I’m familiar with on a more aggregate level is when you expand substance abuse and mental health service benefits, and this research has been done in both Medicaid and in private insurance.  What you see in terms of the reduction in health cost in the same program year and let alone down the road, that data is very encouraging, and it comes from the reduction of emergency room visits and a reduction in accidents, all those things we all see our clients go through and that stuff stops when somebody stops using or at least is significantly reduced.

So, there is actual read data that supports that, and if you want to send me a follow up e-mail, I’ll send you the annotated bibliography I have on that that I got from [01:52:36].

 

Herb:

What is it?  What is your e-mail?

 

Maureen:

I put it on the presentation.  You’ll get it on the presentation.

 

Herb:
Oh, okay.  Fine.  One other thing.  One of the things that I think is really troubling is not just that my clients and our clients here have significant substance abuse issues, but a significant number of them, while they’re out of control with drugs and alcohol and are trying to get it together, end up getting pregnant and having a child.  Then, there’s the whole thing with custody.  Is there a safe environment in their home or not?  Is there anything being done to try to stem what I think is almost like a tide because you just multiple the problems with economic problems as well as with other types of problems when folks are out of control themselves and then they can’t be expected, when they’re out of control, to provide a healthy and safe household in which to be raised.

 

Maureen:

You’re exactly right on the one really big benefit of this broad scale effort to deal with untreated addiction and psychiatric disorders is the impact on families and the impact on community.  I think you’re absolutely right that we pay in so many ways and our clients pay in so many ways and their children pay in so many ways, whether it’s children of people who are incarcerated and everything that they go through or whether it’s children who have an active drug or alcohol using parents.

So, our ability to intervene with that much more comprehensively, think has more of huge payoff for children, and I think it would be interesting to think about what would be a model intervention within a substance abuse treatment program that helps prevent that and intervene more thoughtfully and more directly with that issue.

Also, I think there will be a benefit from the much broader access, and we have a program where we work with parents who have lost custody of their children and are involved in the child welfare system because of their substance abuse.  A lot of those folks don’t get their children back, but we are able to get them sober.  Then, their subsequent children are born drug-free.  So, that’s actually one of our goals in that program is how many drug and alcohol-free births do we have even if reunification is impossible?

So, I really do see what you’re talking about, and I think we need to think about how to take advantage of these expansion of resources to create that kind of outcome for families and for children.

 

Herb:

Okay.  Great.

 

Monica:

That’ll be the last question.  For those of you who have your hands up, I will provide Maureen’s e-mail on the follow-up e-mail I’ll be sending out.

I just want to thank Maureen.  Thank you again for your presentation today. For all of you who participated today, I know two hours is a long time, but thank you so much for joining us.  I just want to make a mention that during the webinar Maureen mentioned several practices such as evidence-based practices, trauma-informed care, Medicaid assisted treatment.  Great Lakes ATTC will be hosting future webinars on those topics because we’re turning [01:56:23] into families, more on re-entry.

At the end of the month, we’re hosting two recovery-oriented systems of care, webinars on theory and practice.  I’ll send out that information, and we’re also hosting a two-day regional re-entry conference October 25th and the 26th.  Day one is in Chicago, and day two literally is in the correctional center.  If you’re interested in attending any workshops or stopping by at any of our exhibit tables at Large Conferences in the state of Illinois, Ohio, Michigan, and Indiana, you can contact me directly at monidela@uic.edu.

For those of you who are not in our four state region, I encourage you to visit our national website which is www.attcnetwork.org. I’ll also send this information, but thank you all.  Thank you, Maureen, and if you have any questions just let us know.

Thank you.
Maureen:

Thank you.  Thank you for hosting this, Monica.

 

Monica:

Oh, you’re welcome.  Okay. Buh bye.

 

Maureen:

Bye.

LEVERAGING NATIONAL HEALTH REFORM TO REDUCE RECIDIVISM AND BUILD RECOVERY P7

There’s going to be a need for greater public health education with this population.  These are folks who generally get their care in emergency rooms and jails if at all.  So, they’re not used to utilizing services, and we have to help them understand what their new rights and capacities are.  There’s also an interest particularly in substance abuse and mental health services conversation about actually physically integrating care so that substance abuse and mental health services and primary care are provided alongside each other.  There may lots of reasons why that’s a challenge, but it is a long term goal in terms of the health care system of the future.

We’re also going to see some new work force issues starting with this change particularly related to what services clinicians are credentialed to provide.  Are the clinicians that we’re used to working with in substance abuse and mental health systems today going to be able to get reimbursed for care in the future?  Lately, we’ve been hearing some very favorable conversations on the federal level about assuring how this happens.  That’s going to need to carry through at the state level.  We at TASC have the opinion that the behavioral health work force of the future needs to include layers of staffing on teams that can include a health care provider like a nurse, a licensed counselor, a certified substance abuse counselor, and recovery support specialist in different combinations for different populations.

So, for some states, that is reimbursable today, and for others, it’s not.  So, how we think this through together is important.  Many states have venues for this.  In Illinois, there’s a work force committee that is being led by the Illinois Department of Public Health.  My understanding is that hasn’t kicked off yet, but when it does, it’s going to be an important venue to have this conversation.

So, the last section of the webinar is talking about planning options.  So, why don’t I just take a last break here, Monica, and see if there’s anything that anybody wants to ask about.

 

Monica:

You know, we have two questions.  We may only have time for one.

 

Maureen:

I’ll let you be the screener then because I can’t see them.

 

Monica:

Right.  Carlo, your hand is still raised.  Hello?

 

Carlo:

Hello.

 

Monica:

Do you have a question?

 

Carlo:

Yes, I have a question.  This is going back to the potential impact of the broad re-entry program, that hypothetical jail model.  There was a statistic on there about a 10% reduction in jail days would yield over $1 million in savings.  I wanted to expand on that.  Is that presupposing that jails might want to reduce that time?  Is there a vested interest?  I ask that because there’s revenues from fines, court costs, fees, the fees mandated pictures such as a substance abuse assessment, victim impact panels, urine drops. So, people are getting charged for each and everything.  It’s a big source of revenue.  So, I question, really, if there’s a motivation to reduce those number of days or inmates in jail.

 

Maureen:

I think that’s a very perceptive question, and there are a lot of market influences that would reinforce what you’re saying.  I don’t know that, on their own, the sheriffs and jail administrators whose funding comes from that would necessarily go there.  There are certainly a lot of folks who run correction institutes who do have a strong commitment to re-entry services.  So, I think it’s a mix. I do think that the person in your community who has the biggest interest are the people who manage the county budget, and so, it may be a question of having the conversation with the right folks.

I know that we’re very concerned about if there’s a substantial reduction in incarceration and what you do with those jobs.  There’s a number of issues related to that, but we think that there’s a lot of potential for those jobs for community supervision. As part of this alternative, you have to rethink how you’re going to use your work force in a different way.  So, certainly, these are sensitive issues and controversial issues, and there’s a lot of both economics and politics at play, but I think the communities who are determined to take advantage of this situation really can.

Ten percent reduction may not be politically [01:32:50].  So, that’s why I didn’t say, “What’s a 25% reduction?”  We started with 10% because we thought it was more palatable for the stakeholders.

 

Carlo:

Okay.  Thank you.

 

Maureen:

Sure.

 

Monica:

Okay.  We can continue, and I have the names of the other people who had their hands raised so we can probably take that at the end of the webinar.

 

Maureen:

Okay, great.  Thank you for being the producer.  Alright, good.

The first opportunity and I’ve talked extensively about different aspects of this but just to pull it together, the first opportunity is earlier interventions and sustained services identified by broad based screening, screening everyone who comes into the system, intervening before conditions become deeply entrenched and chronic.  In the progression of a chronic disease like diabetes, the earlier you start to intervene, the less the complications are going to be and the less expensive it’s going to be and the better the outcome is going to be.

The same is true for substance abuse and mental health care as well.  So, the sooner that we can get the people, the better.  The more overall expansion certainly the more it incorporates practices that we know produce reliable results, the better results are going to be.

Opportunity number two is implement protocols for screening, and this is inside the justice system.  So, the justice system is determining to what extent you want to employ screening tools to determine eligibility.  Eligibility is not the right word here but screening tools to determine need for the kind of services that now the care’s is going to be extended for and also implementing the enrollment.

There should be a process to assess clinical need and public safety risk, and there are an increasing number of tools even very short tools that can give some guidance about that.  In a busy jail, when you want to be able to determine who it is a good idea for me send for treatment in the community instead of being here, you want to take that into account.  It’s actually important.  There are some good tools that can be used both for the screening and the public safety assessment.  I guess I would add on National Institute of Corrections on here, which I will do for the next time I give this.  An early screening also informs what participation people can make in many treatment alternatives.

The third opportunity is the justice system as a Medicaid enrollment partner.  The more streamline the state’s process for enrollment is on eligibility verification is, the easier it’s going to be to enroll people in jail.  Most people, when they get arrested, don’t have a lot of identification and documentation on them.  Their ongoing use and/or psychiatric disorders may make it difficult for them to go through an extended application process and just a lack of familiarity.

So, state Medicaid directors and insurance directors, because it’s usually the two together who are doing this work, play an important role in establishing procedures.  So, in Illinois, we’ve gone to these folks and said, “Look at the number of people we’re talking about here when you take into account all the people in jails, all the people on probation, all the people coming out of prison.  This is a significant group of your likely new enrollees, and we need to have smart systems that really help create the kind of health outcomes and cost reduction outcomes you’re looking for because if these folks continue to show up in emergency rooms and get really very expensive care, this isn’t the best situation for anybody.”

There’s been a little bit of work done on this by the Kaiser Family Foundation not specific to incarceration but specific to outreach to newly eligible populations, and they’ve identified what some of the barriers are.  Again, I mentioned electronic medical records earlier, but the capacity for people to leave with medical information and leave with valid Medicaid cards, that’s an incredible change in the system.

The fourth opportunity is really balancing clinical intervention and public safety at each point.  We’ve talked about how these resources can provide the basis for very broad expansion of diversion and re-entry and community supervision, which requires that people participate in substance abuse and mental health treatment virtually all the way across the criminal justice system.  Some of the things that need to be done preferably by the criminal justice system in combination with the community treatment providers is developing legal eligibility criteria for diversion or specialty supervision programs, developing the community supervision requirements, using both to inform the scope and scale of likely population demands for services for providers, using validated risk tools and evidence-based practices, and also avoiding net widening.  That’s the caution here is we don’t want to make any of the requirements at the risk that a lot of people wind up getting incarcerated as a result of participating.

There is an interesting thing that people need to be aware of which is a requirement in Medicaid for patient choice of providers.  It may seem a little apathetical in the criminal justice system where you’re used to saying, “You’re going to treatment, and it’s at this provider.  Here’s intake date.  Go,” and what Medicaid requires is a choice among appropriate service providers.

So, one of the things that we did was an access to recovery initiative here in Illinois.  We piloted this.  So, what we did was we did the enrollment and referrals to treatment.  We said to people, “You have to go to this level of care because this is what’s warranted based on your symptomatology, your history, everything, but here are the providers you can choose from who are in your area,” and if they didn’t want any of this, “Here are the ones outside your area.”

We found that there was quite a positive response.  People were absolutely overwhelmed that they got to choose their provider.  They got their preference to result in better engagement.  They were very pleased with how that turned out.  So, it may seem like it couldn’t work, but it actually worked really well.

A little bit more on net widening in this slide just to specify the issues we want to avoid, additional technical violations we want to avoid, lower risk offenders placed into more intensive supervision just to get access to care.  We want to have a good partnership between providers and criminal justice professionals on this issue.

In terms of planning, I mentioned a few times the process of planning process we’re doing in Illinois.  Different states, because of the relationship of their state to the national health care reform law, may be in different spots on this.  Illinois is very supportive and going right down this road.  Other states are holding back, and that’s every prerogative to make their decision.

In states where it’s possible, this can be done at the state level, but it can also be done at the community level.  So, this is to think about your local politics and how things fall out, but if your criminal justice system is already engaged in behavioral health treatment and your community health providers work with the criminal justice system, you have the building blocks.  There’s just some additional partners like Medicaid and insurance that needs to be brought into the conversation.

So, in terms of recommendation, we certainly recommend that you take a systems approach, incorporating the essential elements that are required to build recovery, balance the sanctions and rewards process in the criminal justice system to promote engagement, promoting client recovery from substance abuse and mental health conditions, and involving the community where offenders come from and almost all of them will be returning to.

Some of the components of care continuity for justice populations are on this slide:  Screening, comprehensive clinical assessment, placement in community substance abuse and mental health services, ongoing care management to support engagement and retention, and to report regularly on compliance to the criminal justice system.

Important elements of the infrastructure that try to get the whole focus to shift from an acute, episodic treatment to sustained, chronic disease management and support long term, durable recovery not just the cessation of use.

Often today, we only have access to enough treatments or get people to managing that acute use, but really there’s a much larger goal here.  Building community recovery capacity is also valuable. It will probably not be funded by the Medicaid expansion, but it is definitely something to take up in the context of all this planning, good planning that we’re going to do anyway.