Turning consultations into impressions, or 'The tale of three blondes'

March 19, 2015
It has recently come to my attention that patients who visit my office are often confused - but not because we don't explain ourselves clearly and not because we don't answer questions proficiently. Instead, it happens because we have three blondes as part of our dental sleep medicine (DSM) team.

Erin Elliott, DDS

It has recently come to my attention that patients who visit my office are often confused - but not because we don't explain ourselves clearly and not because we don't answer questions proficiently. Instead, it happens because we have three blondes as part of our dental sleep medicine (DSM) team.

You see, it is our goal to take impressions at every consultation appointment for patients who have had sleep studies. In order to do so, Bri handles our iPad consultation, which includes overviews of sleep apnea, health sequelae, sleep hygiene, treatment options, and finally, the oral appliances we provide.

I, another blonde (I tried brown for a three-week period once), meet with each patient following Bri's iPad consultation. During my consultations, I discuss patients' sleep studies, examine their oral health, assess them for TMJ, and evaluate their airways. This enables me to determine whether they are good candidates for oral appliances and, if so, what kind.

I also begin the informed consent discussion at this stage. Notice that I said "begin." Of course, I do not proceed with impressions until I have had a complete informed consent discussion, but why go into too much detail before the patient even knows what his or her financial commitment will be? Why would you give a patient a worst-case scenario before he or she even knows whether insurance will contribute? "Excuse me, Miss. I know you really want to buy this dream home, but I should tell you that you are going to have to replace the carpet, dishwasher, and paint at some point. There is also a chance that it will be destroyed in a tornado, flood, or earthquake. Are you sure you want to buy it?" You cannot judge what is most important or valuable to a patient; therefore, focusing on the what ifs and the negative possibilities doesn't benefit anybody until the patients understand what you are providing for them.

Consider a prescription drug commercial. For example, when my mother-in-law got implants, I remember the informed consent video the oral surgeon showed her. Side effects include: pain, swelling, infection, rejection, permanent numbness, and even death. She looked at me with wide eyes. I had to say, "No ... you won't die. They have to say that. All of this is case-dependent and rare. You'll be just fine." And she was.

Enter Brittany, who is, in fact, the third blonde. Before a patient even enters our door, we have our third-party biller send an insurance verification (i.e, breakdown of medical insurance benefits), printed and ready. This is critical because we can determine the difference between the in-network deductible vs. the out-of-network deductible, and we can figure out what the co-insurance will be. We can also find out if we can bill at the in-network level to save the patient costs or if the patient's out-of-pocket maximum is close to being met, etc. In addition, we have the patient's sleep study, consultation notes, and referral in hand. Once I have finished consulting with the patient and answering his or her questions, Brittany comes in with a financial arrangement and the patient's benefits on a clipboard.

She sits right next to the patient, as a friend and advocate. I will tell you that her job becomes much easier at the end of the year when most patients' deductibles have been met and their out-of-pockets are minimal. We normally collect $400 to $700 up front, depending on the patient's deductible and co-insurance, to cover the lab fee. We do this partially because the patient might choose not to proceed, but we also do it because it provides the patient with the feeling that he or she has committed to treatment and has invested in his or her health. As an out-of-network provider, which most dentists are, you may wonder about how I collect a sum as low as $400 when most deductibles are much more costly. The answer is that we are successful at obtaining in-network coverage (also known as GAP exceptions) for our patients. So if a patient has a $1,000 out-of-network deductible with $0 met and a $500 in-network deductible with $300 met, we instantly save the patient $800 out of his or her pocket. Patients also get to save by being able to use their in-network co-insurance, which will usually save them another $500 or more. Whenever we can save a patient that much money, we greatly increase our chance of treating the patient. The one question that every patient has is: "How much is this going to cost me?"

More often than not, a preauthorization is required; therefore, we take the impressions and hold them until that is received. We then call the patient before mailing the impressions and proceeding. We don't bill out until delivery and can only recall two patients out of hundreds who did not move on to the appliance. I think our success with this matter can be attributed to two reasons. First, and most importantly, we have built value into what we do for the patient. And, second, the patients know what to expect and, for the most part, what their financial investment will be. There are not many surprises. The only surprise is which blonde they will talk to next. Isn't it much easier to have a financial conversation in person (rather than over the phone), instead of scheduling a separate appointment for impressions and then another for delivery?

There are times when we have to reschedule for impressions, but most of the time, I have back-up team members to help. We turn the room over and set up the impression trays, impression material, bite registration, and paperwork. We even have logoed moist hand towels in a crockpot to help clean up the patient afterward. (There are a lot of beards in Idaho!) The patient leaves happy, and we are happy. Win-win.

DSM has been a part of my general dentistry practice for five years, and in that time, I have made many mistakes. I have had systems that didn't work and team members who were in the wrong place. Two key changes have improved my practice: I hired a third-party biller, and I began cross-training the team. My third-party biller frees up time that was previously spent checking on patients' benefits. My billing company also applies for GAP exceptions, sends preauthorizations, and goes back and forth with insurance companies for us. From the person answering the phone to the hygienist, every team member has a job to do and is educated on sleep apnea. I used to have one team member try to do it all. Her stack of sticky notes with messages from patients would be a mile high at the end of the day. When more questions can be answered at the front desk, more sticky notes are saved from their demise. I have a clinical assistant who handles deliveries, adjustments, follow-up appointments, and lab tracking of impressions and appliances. My office manager works with the third-party biller, makes financial arrangements, and answers patients' billing questions. My dental insurance guru also tracks medical insurance payments, as well as referrals and other paperwork for insurance companies. I also have two other clinical assistants who take impressions, do deliveries, and make adjustments.

Medical insurance is daunting. Patients and dentists alike can become overwhelmed easily. The verification, the preauthorizations, the paperwork ... OH MY! Do not fret, my friend; you can navigate this. It is rare that an insurance company doesn't cover an oral appliance. Sometimes, however, the appliance is denied at first, or there is another "in-network" provider, or you go back and forth with the insurance company until you get GAP coverage or approval. It is worth the effort and the fight. Why? Because your patients will thank you, your team will get excited, and it can help your practice's bottom line. Systems with specific job duties for specific team members ensure that the loop gets closed and that patients get the treatment they need in an organized and timely manner. Set yourself apart, be better than you think you can be, and help save your patients' lives.

Prior to arrival (patients from hygiene appointments, phone calls, or physician referrals):

• Always reschedule a recare patient for an official sleep consult.

• Set up four units (40 minutes) for a patient without a sleep study and six units (60 minutes) with a diagnosis.

• The team member who answered the phone call or made the appointment is responsible for tracking down the sleep study to send for insurance verification or for calling about insurance verification if the office is not using a third-party biller.

Insurance verification:

• What is the patient's deductible?

• How much of the deductible has been met?

• What is the co-pay in-network vs. out-of-network?

• Are there any in-network providers?

• Is GAP coverage available?

• Is preauthorization needed?

• What is the patient's expected contribution?

• Create a financial arrangement.


• Patient needs to have completed the appropriate paperwork and questionnaire (preferably online).

• The insurance verification should be ready.

• The sleep study results should be ready.

• Any physician consult notes should be on hand.

• A referral should be ready.


• A financial arrangement should be determined.

• Informed consent should be obtained.

• The patient needs to complete a continuous positive airway pressure (CPAP) affidavit.

After Impressions:

• Request preauthorization, if needed.

• Apply for GAP coverage, if needed.

• Call the patient with approval.

• Send out impressions.


• Complete proof of delivery paperwork.

• Bill for the appliance in a superbill, listing all services to date with an accurate date for each service.

Erin Elliott, DDS, is in private practice in Post Falls, Idaho, where she provides general and cosmetic dentistry, short-term orthodontics, and dental sleep medicine. Dr. Elliott is an active member of the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine, as well as a diplomate of the American Sleep and Breathing Academy. She has authored several articles and lectured extensively on dental sleep medicine. Contact her at [email protected].

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