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.



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.



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.”


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.



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.



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.


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.



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

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