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.