Filing Insurance For Oral Appliance Therapy

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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.

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