Medical Insurance for Oral Appliance Therapy

for Sleep Disordered Breathing

Ellen Crean, MS DDS PHD

Owner at Triton Medical Solutions LLCPartner at Kosmo Technologies LLC

Disclosure:

Course Objectives:

• Understand the difference between medical/dental insurance1

• Operating your practice as insurance medical model vs. fee for service2

• Medical insurance for oral appliance therapy for obstructive sleep apnea3

• Commercial Insurance4

• Medicare5

• In network vs. out of network contracts6

Course Objectives:

• Operating billing from your office vs. utilizing the services of a billing company7

Course Objectives:

Dentists Billing Medical Insurance

1. For services within their scope of practice

2. Different than dental insurance

Insurance can not deny payment to a provider based on type of provider, if it is a covered benefit of the plan under the scope of practice of that provider.

How Differs from Dental Insurance

• Patient is not limited to small amount of coverage per year1

• Covered benefit codes linked to specific diagnostic codes2

• Many more steps to payment3

Medical Model vs. Fee for Service Model

ProsWhat MD’s & patients want

Makes treatment more affordable

More case acceptance

More referrals

ConsHave to abide by

insurance company rules

Multiple steps to get paid

Work with allowed amounts

Wait for payment

Benefits of switching to medical model as DDS

ProsCharge what you

want

Get paid right away

Less work

ConsMD: less referral used to patients being covered by

insurance

Less case acceptance

More money for patients

Patients go to in network provider

Benefits of staying with fee for service model as DDS

Patient Perspective of Medical Insurance

that insurance recognizes.

In the medical model the

opposite is true

covers and put added value on

treatment

Patients tend to do

what insurance

Dental Services that can be Billed to Medical Insurance

Oral Surgery Procedures

TMD Related Services

Some Radiological

Services (based on appropriate

ICD-9 code)

Sleep Breathing Disorder

Treatment with Appliances

Sleep Breathing Disorder Treatment with Appliances

Covered ServicesExamsX-rays

RhinometryPharyngometry

Appliances

Medical Insurance terminology to know

Provider NPI

Rendering NPI

Referring NPI

ICD-9

CPT

HCPCS

DME

Participating Provider

Non Participating Provider

In Network

Out of Network

Deductible

OOP

Gap Exception

Network Insufficiency

LOA

EOB

EFT

Pre-Auth

CMS-1500

HIPPA 5010

Modifiers

Clearing House

Tax ID

DME

DME POS

Electronic Billing

ERA

Types of Insurance You Will Encounter

Types of Medical

Insurance

Commercial

Medicare

Medicare Replacement

Medicare SupplementalMedicaid

Private Plans

Independent Payers for

Commercial Plans

Medical Insurance Coverage for Oral Appliance Therapy for Sleep Disordered Breathing

Oral appliances:

Oral appliances are a covered benefit on

medical insurance and Medicare plans

They are covered under DME POS (custom durable medical

equipment)

They must have diagnosis of obstructive sleep apnea or upper airway resistance syndrome to

be covered

Most insurance companies require electronic billing

Steps for Getting Paid

Eligibility, Benefit, Deductible Check Pre-Authorization Gap Exception

(if necessary)

Electronic Bill EFT or Payment (EOB)

Appeal(if necessary)

Clinical Documents Needed for Pre-Authorizations

• Diagnostic PSG Report (diagnosing apnea)

• RX from MD who has seen the patient

• Documentation of CPAP trial or letter from MD stating why CPAP not recommended for patient

• GAP exception request (if necessary)

• Narrative describing appliance with FDA # or PDAC #

• NOTE: Some insurance companies are now requesting invoices from lab as to what manufacturers retail price is

Pre-Authorizations

• Most insurance companies require pre-authorization for E0486

• Some will give pre-authorizations for a specific date of service, others will allow a 3-6 month window when service can be performed

• In order for insurance to pay, patient must be seen for treatment within valid pre-authorization time frame

• Must wait for pre-authorization and GAP exception before seeing patient in order for them to be valid benefits

• Pre-authorization and GAP exceptions can take up to 12 business days to obtain

Commercial Insurance (HMO’s & PPO’s)

HMO’s

Only in network benefits

Usually lower deductibles

Most have own copays

PCP usually needs to initiate pre-

authorization and referrals

Can get GAP exceptions if no

in-network providers

PPO’s

In & out of network benefits

Variable deductibles

Some have co-pays

Patient has choice of doctor

to see

Most will approve GAP exceptions (some will not)

In-Network Benefits vs. Out-of-Network Benefits

In-Network Benefits

Higher percent of coverage ex: 80/20

Usually lower deductible

Allowed amount or negotiated fee schedule

Payment goes to provider

Out-of-Network Benefits

Lower percentage of coverage ex: 60/40

Higher deductible

Patient responsible for difference between billed amount and allowed amount

Payment goes to patient

Contracts

In-Network

LOA’s

GAP Exceptions

In-Network Benefits vs. Out-of-Network Benefits

In-Network Benefits

Higher percent of coverage ex: 80/20

Usually lower deductible

Allowed amount or negotiated fee schedule

Payment goes to provider

Out-of-Network Benefits

Lower percentage of coverage ex: 60/40

Higher deductible

Patient responsible for difference between billed amount and allowed amount

Payment goes to patient

Medicare

• Oral appliance covered under custom DME POS

• Dentists can obtain a provider/supplier DME POS contract with Medicare (application, site visit & must follow DME supplier standards)

• DME divided up into 4 jurisdictions in US

• Jurisdiction D has set fee of: $1,290.00

Medicare Standards

Medicare has standards set

for billing oral

appliances

Must be billed for and provided by a

dentist

Wants global code E0486 to cover all

treatment from time decision is made to

do appliance and 90-days after delivery

Must use a PDAC approved appliance

With Medicare you are either:

1. Opted Out (need informed agreement from every patient

2. Participating provider3. Non-participating provider

Benefits of Medicare

No pre-authorization

required

Maintain clinical

records in patients chart (if requested)

Payment by EFT

Payment generally in account by 15 days of

billed.

Medicare and Supplemental Insurance

Medicare will automatically send to supplemental insurance for payment electronically

Medicare has yearly deductible (around $140.00)

Can bill Medicare patient for remaining 20% if no supplemental insurance

Most Medicare patients have supplemental to cover remaining 20%

Medicare pays 80% of allowed amount

Internal Office Billing vs. Billing Service Company

In-Office

Staff to learn new process

Time on phone or computer to do eligibility & benefits checks as well as pre-authorizations

Sending clinicals to insurance companies

Must be electronic so need software and clearing house setup

Tracking claims

In-Office

Resolving appeals

Evaluating EOB’s

Appeals & denials

Communicating with insurance companies

Contracts, applications and follow-ups

Billing Company

Know how to register you with insurance companies for efficient payment

Takes everything out of your hands

Know how to deal with insurance companies

Has relationship with insurance companies

Will get contracts for you

Manages all accounting related to billing

Internal Office Billing vs. Billing Service Company

Lots of staff time frustration

Office Billing

Less staff time

Claims Paid

Billing Service Company