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.