I'm watching my kids swim once again, as we recently got a pool. We live in northern Idaho-don't ask me about the logic. In fact, I think our house appraisal went down with that decision, but who said I was ever rational? As I watch my two boys tread water, I try to tell them that treading water is actually harder than swimming. "Just keep swimming, just keep swimming." Isn't that a line from Finding Nemo? So many times, dentists continue to tread water because that is what they know and that is what the dentist before them did. What would it be like to actually swim? Save your effort, save the stress, and start swimming in the right direction.
The analogy I'm providing is basically explaining the difference between a routine (treading water) and a system (swimming). As the wise Chris Salierno, DDS, says, "I should clarify that there is a difference between a system and a routine. Systems are periodically tested, evolved, and proven. Routines are the things we do just because we did them that way yesterday."1
Dental sleep medicine is an area where the battle between routines and systems is apparent. It can be routine to make snore guards. I always love when I get a call from a local dentist's office asking, "What code do you bill to dental insurance for a snore guard?" My administrative team always answers, "What was the AHI on the PSG or HST?" As soon as the person on the line says, "Umm," we know that there was no sleep study done. Making the appliance is the easy part, but there is so much more to dental sleep medicine than taking two alginates and making a snore guard. Taking impressions is routine . . . and easy. Delivering a mouth guard or snore guard is routine . . . and easy. But what about side effects? Routine? What about billing the patient's medical insurance? Routine? Or do you need a system to allow you to follow the patient from A to Z and work with the medical community? After all, it is a dental solution to a medical problem.
First of all, there are over 100 FDA-approved sleep apnea appliances. Which one do you use and in what situation? Do you base it on lab price, or do you base it on what is durable, comfortable, and accommodating to the patient's anatomy and physiology? In addition, it is imperative that you test the patient for obstructive sleep apnea (OSA). OSA is a dangerous and sometimes deadly disease if left untreated. What happens if you make a patient quiet by taking care of the snoring but you are not actually treating the patient therapeutically? Unless you have baseline and follow-up sleep studies, you would not know. You're playing with liability fire.
OK, the lecture is over and I'm stepping off my soapbox. Now onto how to properly bill true oral appliance therapy. My sleep patients come from various sources: existing patients, external marketing, and physician referrals. Step one is to make a separate consult appointment even if the patient was screened in your dental chair. (Editor's note: Access Dr. Elliott's previous article at bit.ly/2d9v78i.)
Next, e-mail or mail the paperwork to the patient prior to the consult appointment. Paperwork? Yes, there is a lot of it, but the medical insurance provider needs to know that we have seen the patient face-to-face. Included in the paperwork is something called an Epworth Sleepiness Scale. This allows the medical insurance provider to know that the patient has excessive daytime sleepiness caused by sleep apnea. Although I feel the Epworth is useless because patients downplay how tired they are, medical insurance requires a score of 10 or more to consider patients to have excessive daytime sleepiness (EDS), especially if they only have mild sleep apnea. We also look at demographics, medical insurance information, previous therapies, health history, and medications. After my dental sleep medicine coordinator is done with the consult, I will come in and review the patient's sleep study. Prior to the consult, we request any previous consult notes and the sleep study if one was done. It's pretty amazing to see the light bulb go off in the patient's head when they say, "Wow . . . no wonder I'm so tired. No one has ever explained that to me before." The value in what we provide has been received.
Then we go over the insurance verification, also known as the verification of benefits. While you can use a third party to bill, you can also follow these questions and have an astute employee call. The CPT-10 codes that we ask for coverage on are:
• 95806: Home sleep test with effort belt (we use this one);
• 95800: Home sleep test without effort belt; and
• E0486: Custom lab-fabricated oral appliance, adjustable or nonadjustable.
The E0486 code is considered durable medical equipment, in the same category as CPAP, oxygen tanks, and wheelchairs, for example. Note that it is a custom oral appliance, not a boil-and-bite or chairside appliance. In addition, it is an "E" code, which is medical. A "D" code is a dental code and rarely covered; even if it is, it is at a much lower fee. We also bill for radiography, exam, and impression codes, but we don't check coverage on those.
In addition, medical insurance requires a diagnosis code of G47.33 obstructive sleep apnea, adult or pediatric. In most states, all you need to have is a sleep study signed by a board-certified sleep physician. I work with several sleep physicians in my town, and one that reads studies online, in order to get a diagnosis. The Apnea-Hypopnea Index (AHI) needs to be 5 or more. Therefore, every patient we send home with a home sleep test gets a free small bottle of Idaho potato vodka (I'm joking) as alcohol relaxes smooth muscle and can make sleep apnea worse. It's just for diagnostic purposes of course. The following are additional questions that need to be asked:
What is the in-network deductible?
What is the out-of-network deductible?
How much has been met of each?
What is the coinsurance? (This is different than copay.)
Is a preauthorization required on these codes?
Is GAP available?
Is there a DME maximum?
Is there an out-of-pocket maximum? How much has been met?
Who you are talking to and what is the reference number for the call?
Are there any other in-network providers?
Phew! Are you tired yet? Believe me, it is worth it. At this point, we can get a good estimate on the patient's out-of-pocket cost as long as you have some history and have a good idea on the allowable.
The only other question we need to know is whether or not we are an in-network or out-of-network provider. My advice is to always stay out of network, but there are a few cases in which being in-network with dental insurance makes you automatically in the network with medical insurance. Believe me, this is a hurdle I am trying to overcome with Blue Cross of Idaho. Additionally, there are a few cases in which an in-network provider doesn't provide the oral appliance service. Therefore, it is important to ask who the in-network providers are if the medical insurance will provide it for you (sometimes they won't). Many times we can get an in-network exception even though there are other in-network providers. This is called GAP, and the usual culprits are oral surgeons as they provide trauma coverage instead of oral appliances. Medical insurance hates out-of-network providers, but I was never one to follow the rules. The advantage to staying out of network is that you can balance bill the patient. We have a set "minimum amount accepted." If Blue Cross Blue Shield of whatever state's allowable is $900, then the patient would be responsible for the rest. Some allowables are so low that they don't even cover the lab costs. You can see how being in-network would be a disadvantage as you are stuck with the allowable and waive your ability to balance bill.
In the next article we will go through a few examples of how to determine the patient's out-of-pocket costs and a sample insurance verification. Fun stuff, I know, but hang with me. If you can get these few things down, then you will not only create lifelong grateful patients but also raving fans! Stop making snore guards and start saving lives by getting invested in training and learning. Isn't that what dentistry is about-continually learning and continually working for what is best for our patients? Get out of your routine of treading water and create steadfast systems that can benefit your patients and your practice so that you can start swimming.
Erin Elliott, DDS, is a practicing general dentist in Post Falls, Idaho, where she has successfully integrated dental sleep medicine into her busy general practice. She lectures extensively and leads a hands-on workshop focusing on practical strategies for successful implementation into the busy general practice. She is an active member of the American Academy of Sleep Medicine and American Academy of Dental Sleep Medicine. She is the president and a diplomate of the American Sleep and Breathing Academy. She can be contacted directly at email@example.com.
Editor's note: This article is part two of a quarterly series. Part one appeared in the June 2016 issue of DE.