Welcome. I'm Dr. Mayit Sergulat, a moderator for this evening's webinar on Billing and Coding Q&A. I'm joined with our panelists, Dr. Alex Vaughn, Belinda Postol, Angie Cooper from CGS Administrators, and Cindy White from Naradian Healthcare Solutions. And now I will turn it over to Dr. Vaughn, who will be giving a brief overview on the fundamentals of commercial insurance. So let me give you a quick rundown of kind of my background. So I'm an oral facial pain specialist. I practice in Richmond, Virginia. I would call myself a coding lay expert, with an expert being however you want to define that term, either politely or rudely. I certainly am not a trained coder, not that, but my background is in billing, dental billing, originally, prior to becoming a dentist, and then still do enjoy and love, honestly, the benefits that come from using patients' insurances and allowing patients to kind of unlock the benefits they've already paid for. So I do get a little bit of a thrill every time we are able to kind of actualize that for a patient. And then I'll highlight, too, nothing that I have to say is absolute, except when it is. I will try to highlight when it's absolute, but in general, assume that there's always a caveat to everything said. I think coding, billing, insurance, all is just like lawyers speak. We've got the rules, but the rules are always just guidelines, unless they aren't. So I'll try and highlight those. The other person on the call here from kind of those of us talking about in the field and practice side is Belinda Postel. So I'll do a quick intro for her, and she'll, I'm sure, hopefully introduce herself probably much better than I will later, but she's a registered nurse. She's been treating apnea for 15 years, and she wanted to highlight, and I agree with her here, the successes that come from billing and house always. There's certainly nothing wrong with billing services, and I'm sure we're going to get a few questions on that. They're great services, but there's also some pride to be had of knowing that you've been able to do it yourself. But the key that she did not point out, but Trish did to make sure it was highlighted, was that she is a baker and a phenomenal baker at that. So I think those are important highlights for sure. So just a quick guidelines. I want to highlight a few things here. One is my favorite phrase is that these presentations always have a sell-by date. That sell-by date is today. What do I mean by that? Just like when you buy some food from the grocery store, if you buy it on the sell-by date, it might be good for a day. It might be good for two weeks. It depends on what you're buying and what it's for. But everything we're going over tonight is accurate-ish, with a caveat there, of today's date. The reason I've got an exception applying to that rule is on my last update that I gave everyone in May, I updated that I was incorrect on UnitedHealthcare guidelines, that they had made an error in my last presentation because I read their wrong guideline and they'd split it off. They've got a commercial guideline and this marketplace guideline. This was May. I don't remember what date in May. UnitedHealthcare was so gracious to actually end up right after that, backdating and retroactively applying a policy to state that now it applies on May 1st, and it's the same as the marketplace plan policies. So everything I taught originally, that they were going to Medicare guidelines, I was wrong in initially that that was the only marketplace plan. And then they went back in time and retroactively applied a policy and added to their commercial plans. So just because it's accurate as of today doesn't mean insurances can't sometimes retroactively change the rules, but that does happen occasionally. It's rare, but definitely that leads to the next one, which is read your policies. Google's your friend. Go to Google, type in whatever insurance you care about, space, whatever code you care about, space, medical policy, and hit enter. And you'll usually get an answer that you're looking for that's applied to that policy. I know it sounds redundant, but check those every quarter probably because they do get updated. I will highlight certainly Medicare is nice. They tend to update their policies around our usual schedule. And usually, because it is federal, have a notice period and a comment period. So usually Medicare, you get a much better opportunity to influence, well, to make your thoughts heard on the policy. I don't know how much of the influence we get, but you can certainly make your thoughts heard on the Medicare side a lot more than you can on the commercial side. This is the classic saying, but it needs to be said every time, code what you do and do what you code. Don't make up a code, don't make up a procedure. If what you're doing doesn't exist, there are miscellaneous codes for that. Don't build something that you want it to be if it isn't that. Build what it is, and if it doesn't exist, use a miscellaneous code. And that's why I have that next point, there's always a code for that. There is. Every single thing you do has a code. Shaking your patient's hand has a code. Now, insurance won't pay for it, and it's going to be a miscellaneous code. You're going to have a hard time writing it up, but there is a code for shaking your patient's hand. So just, I highlight that because I always get a question, what, you know, can I code for? Yes. But coding, being able to code for something doesn't mean you can get paid for it. So you will, you know, you have to meet medical need. You have to establish that what you're doing is necessary for the care of the patient. Not improves their care, not makes it better, not what the patient wants, not what you want, but it's necessary. And that's the difference between coding and being paid. And then finally, embrace the suck. This is a phrase we learned in the military, and I want to highlight this because it can sound rude, but my point in this is that there are stresses. Every job you do has a stress. Every job your team members do has a stress. And if you simply sit there and say, why are you stressing? You're not going to get any benefit. And so what I have found to be immensely helpful in my own practice was doing a few cases myself. Maybe 10, I would say the first 10 claims, submit yourself. And by yourself, I don't mean your practice. I mean, you as the doctor do it, do the follow-up phone calls, see what questions your team are going to get asked. So you understand what they're going through. You understand why they're perhaps unhappy after an hour long hold to get to the wrong department. And so I really do kind of live by that policy. And I think it's important for us to really see what our team members are doing. So a few insurance steps. I usually have this slide and every one of my slideshows, but I think it's useful to see insurance companies. Best way I like to think about them as three or four separate companies. Okay. You have your patient's eligibility or their benefits. Are they, you know, and that's the benefits department at the insurance. Are they eligible for care on that date? Are they eligible for the service you gave them? Are there any exclusions on that service? That department is essentially a different company than the medical necessity department. So just because company A tells you, yes, your patient is valid for care that day, when you call medical needs department or the utilization management department, as it's usually called, they may have a different answer for you. Not that your patient's not eligible, but just simply that might not be medically necessary. And then you have your claims processing department. Again, almost like a separate company. You might have a prior auth approval from the utilization management team, but if you don't attach that to your claim form, you might not get paid and that's not claims fault and they may not talk well. So just think of these as different companies. And so when you have a problem, you have to deal with the company that you're dealing with, whether it's eligibility, necessity, or payment. The next few slides, I want to preface very carefully. One of my favorite quotes, a day without laughter is a day wasted. I enjoy smiling and making fun of ourselves and others in a kind hearted way. So please don't take what's coming up next rudely. I'm meaning to be funny. So how do dentists view insurance companies? This is how I think we view our insurance companies. I asked my team today what their views are. I think a lot of us view insurance companies as these just giant stop signs that ruin the fun and make sure that no one gets better. I think we think of them as sitting in some room doing nothing with our claim for two weeks, and then finally waking up enough to press the one button to send us a check. Or even, I think I love the cat in the bottom because it really does some days feel like it, where you'll get denials for no reason, it seems. It really does feel like someone at the other end just bashed their head on the keyboard and decided to deny your claim. So I think that's how we view insurances. And I think this is how insurances view us sometimes. I have countless times when I've done a call on a claim, sworn that the other person on the other end is just laughing at us for the questions we ask over why aren't we getting paid. I hope it's not true, but I do imagine that they look at some of us as just demanding payment rather than following the rules. But it's an important reminder, insurance is a contract between your patient and the insurance company. You are not a party to that contract. So the rules that they've agreed to abide by are what the patient and the insurance company have agreed to. The patient is your client, and you may have a contract with the insurance company, but those are two separate contracts and agreements. And what the patient and the insurance agreed to is what determines what they get care for. I use this too to remind myself, and I don't, of course, say this rudely to patients, but they chose their insurance company, and that's okay. Their insurance may allow for certain things and not others. And that's a decision that usually is not clear during the time of selection of insurances, but it's not our fault as dentists or as the provider for what the plans do or don't cover. And there are certain things that the insurances aren't going to cover, and that's fine. It's not our business to tell them what they need to cover. We simply need to live with that rule, and in my opinion, bill cash for those services. But let me take a quick life in the claim. That's kind of what I want to do here. This is the last little bit here. But what does a claim go through? And I want to highlight this because this week at my practice, our practice manager was getting very frustrated with the claim that calling different insurances, and it was an insurance, let's say, a nameless insurance that operates many, many subsidiaries in each and every state as an alliance and union. Maybe one might call it an association of individual plans that are blue. But in this case, what happened was that she was calling the claims department. The claims department was saying, we don't have record of that. They saw the letter we sent them, but didn't have a copy of the claim. And so she's getting very frustrated with that, but it's important to remember the steps that we go through, and that's because this claim was actually blocked at the clearinghouse level. And so I kind of want to walk us through what happens with the claim. So if you're using electronic billing, which hopefully you are, your claims are going to go to a clearinghouse. So what will happen is, obviously, insurances are getting thousands and thousands of claims every day from thousands of different providers, and they don't want to have the infrastructure to manage each and every one individually. So they work through clearinghouses. Clearinghouses take all the claims, put them together, package them, and send them where they need to go. So what's going to happen is all these claims are going to come together. The clearinghouse is going to take them and do usually a first pass evaluation, and then package them and bundle them nicely to the insurance companies in the package that they want, rather than dealing with 100 different ways to send it. So sometimes the clearinghouse is going to reject it, right? The clearinghouse might immediately kick it back to you as the dentist, and you're going, why the heck did it get rejected? What did I do wrong? And the rest are going to get passed to insurance. So some blocks happen at the clearinghouse level. These are usually called exclusions. Again, if you're doing medical or electronic billing, this will get kicked back through your software as an excluded claim, and there'll be a line item on there to tell you what you need to fix. If it gets to the insurance company, they're going to do, again, a first pass and evaluate and determine, is this a clean claim or not? And what that means is, if the claim is clean, it means it's able, it has all of the information necessary for adjudication or evaluation by the insurance company. So what are they going to be looking for? They're going to be looking for, is the patient's name on there? Is the identifier correct? Is the data service there? Is their date of birth on there? Now, in the electronic claim age, this is much easier because all that data pretty much gets put on the claim for us, but especially with paper claims, it's easy to miss a line item that's necessary. And so their first check is going to be, do we even accept this claim? And if they do, then it's considered a clean claim. And that's an important phrase because most states, if not every state, have laws that state wants, interns have a certain period of time to determine if there's a problem with the claim submission. And if they don't determine that, or if they've decided it's a clean claim, they must accept it and they can't hit you for a timely filing error or an issue like that. Now, it doesn't mean they need to approve it, but they do need to accept it. So certainly that's a state. Now, it might get rejected. In that case, again, a lot of times it'll come back. I'm hoping our Medicare folks are happy that I'm going to highlight this. Number one exclusion for us on our electronic claims is we're missing the last four digits of the patient's nine-digit zip code. And that final four matters for claim processing. And so on our Medicare claims, we always have to make sure we've got all nine digits on there. And that's certainly one, if you're getting a lot of rejections, it wouldn't surprise me if that's what it is. But otherwise, a multitude of other reasons, mainly if the claim is filled out correctly, then they're going to evaluate it. They're going to break it up line by line, and they're going to decide, do we pay this line? Do we not pay this line? So some lines might go to the pay column, some might get rejected. And then also at that stage, they're going to determine, again, that's kind of more medical necessity stage. Do we accept or reject these coding lists? You can't bill this with this service. You put the right modifier on there. If you bill a rental oral appliance, for example, most insurances are going to kick that back. Then you can't rent an oral appliance. It can only be a new appliance. Then it's going to go to the claims payment department. They're going to apply the logic that goes on a claim. They're going to do the bundling logics that, hey, you did a same surgery, double-site surgery, bilateral surgery, we're going to cut the payment in half for the second one, whatnot. They're going to now take your broken up claim where it was line by line evaluated and put it back together into a single payment. So they're going to put it back together into an EOB or an ERA, depending on what phrase you want to use there, put it all back together, and then hopefully send you a check or at least the ERA to tell you why you aren't getting a check. And then we get to look there and be confused by why it wasn't as much as we wanted. But again, just to show you these guidelines, again, I think these are important to highlight, but I hope that is a quick overview of kind of the claims process, but I hope that helps to understand each of those stages can be a problem and what you're trying to fix depends on what stage it's in. So certainly learning that's important, but that's what I got for you. Great. Thank you, Dr. Vaughn. And now our Medicare panelists, Cindy White and Angie Cooper, I apologize, will provide a brief overview of Medicare basics. And after that, we can begin the Q&A portion of this webinar and feel free to submit any questions using the ask button on the right-hand side of the screen. So hello, everyone, and welcome. How lucky are you to be spending your evening learning about billing coding and now talking to the representatives from Medicare on a fun-filled Thursday evening. So I am Cindy White, and I represent Noradian Healthcare Solutions. We have the Medicare DME or DEMI POS, durable medical equipment orthotics prosthetics and supply contract for jurisdictions A and B as in dog. And my colleague Angie is here, and you'll be hearing from both of us. She represents through CGS the jurisdictions B as in boy and C. So you have the entire United States represented, and hopefully we can answer all your questions. We don't have the wonderful graphics that Alex did because we're with the government, and we keep things pretty bland. I did love his comments about the fact that if you don't like the rules, wait 10 minutes because they might change. It's sort of like the weather here in the Pacific Northwest. But his disclaimer is accurate that everything we will share tonight is as up-to-date as possible. But for Medicare, like all insurances, things do change. We do try to inform you. Thank you for the kudos that we do try to inform you with Medicare. And with that, I'm just going to get started on a few slides. We'll talk about basics, and then Angie's going to talk about a little bit about appeals because that's one of the places that we found that the dental community didn't really understand what their options were there. And then we'll take questions because really you didn't come here to see our slides. You came here to get your questions answered. So assuming I can make my slides move, let's see. It's always nice when the plan works. There we go. Okay. If you press the right button, technology and I don't always get along. I think I skipped one. All right. So for Medicare purposes, there's one custom fabricated code that we will cover. The E0486. Use to treat OSA. That's it. We require that there be a face-to-face evaluation by the treating practitioner, and that's the practitioner treating the OSA. They evaluate the beneficiary for what their signs and symptoms of sleep apnea are. It can be their primary care physician. It can be a sleep doc, but they talk with them about snoring, daytime sleepiness. They look at their bills, all of those things, but it has to be a face-to-face with that practitioner treating for OSA. Then it has to have a Medicare covered sleep study, which we'll go over on the next slide what the requirements are. And then that oral appliance has to be ordered by either the individual that did the face-to-face study or another practitioner who has access to those records who is either a sleep doctor or their primary care physician. We understand that you are treating the beneficiary as well, but in this particular, for these circumstances, it is a medical doctor, MD or DO, that would be treating and being able to order the study and order the device. And then, of course, the device has to be provided by a licensed dentist. So that's where you all come in as the licensed dentist who are DME suppliers in this instance. That sleep test that gets done to evaluate for the OSA has some parameters, and these are all listed in the local coverage determination for oral appliances used for the treatment of obstructive sleep apnea. And the AHI or RDI has to be greater than 15 events per hour with a minimum of 30, or the AHI or RDI can be between 5 and 14 events per hour with a minimum of 10. But if that's the case, it's relatively mild. So there's a requirement that there be some additional symptoms, and it doesn't have to be all of them, but it could be one or more of the excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or a history of stroke. So like I said, it doesn't have to be all of those, but there has to be some indication that there's a potential for OSA if they have that lower AHI or RDI. And then also, if they have a very high AHI or RDI, so greater than 30, then there has to be a trial on the CPAP or the bi-level device, and that beneficiary has to have shown that they're unable to tolerate the PAP device in order to move to an oral appliance. Or the treating practitioner, again, that practitioner is treating through the OSA, can determine that the PAP device itself is contraindicated. One thing I should mention, we're not going to talk a lot about this, but one thing I should mention, we get a lot of questions these days about accepting REI, and at this time, the Medicare program does not accept REI. We accept AHI or RDI. So we have a little flowchart here too, and I'm sure you have access to these slides. From our perspective, it's all about asking the right questions, and we know you know this, but we like to maybe use these slides to prompt additional questions. So if it seems sort of rudimentary, we apologize, but sometimes those sparks questions. So ask the beneficiary who's coming in to see you, have they been treated for sleep apnea? Have they ever used a PAP device? Also, have you previously had an oral appliance? It's surprising, as you may have experienced, how often that has occurred. And then check the DME website. All four of the jurisdictions have portals where you can check for same or similar equipment. The problem is, if that patient has lived in more than one place throughout the United States, you would have to check the portal for every jurisdiction that would cover the state in which they lived in order to be able to see that they had, whether or not they'd had a device or not. And then make sure you get a prescription from that sleep doctor. We call those standard written orders, and make sure that that face-to-face occurred and there was a qualifying sleep study. The answers to all those questions help you in determining whether or not you can service that beneficiary. Keep wanting to use my mouse instead of my arrow keys. I need to just keep my hands off my keyboard. So, things that are really important that we find the dental community in particular, although sometimes the PAP suppliers too, running into are the same and similar denials. And because an oral appliance treats the same disease, obstructive sleep apnea or OSA, that the PAP device does, those two pieces of equipment, if they're built in a five-year period of time, the second one billed will deny for same and similar. Now, if there's been a change in the beneficiary's condition or something has occurred that they're no longer able to tolerate the PAP device, if they're coming to you for an oral appliance, it's a possibility that we would change or we would pay for that new device. However, there must be clinical documentation that shows that there's a significant change requiring the movement from a PAP device to an oral appliance. If that does not exist, you as a supplier have the right to offer that advance beneficiary notice of non-coverage or ABS and collect from them. So keep that in mind as you're working with beneficiaries who have been on PAP. You can appeal any claim that for an oral appliance that's denied because of a previous PAP, but you will have to produce that documentation. Keep in mind, we talked about on a previous slide that allowed to order for DME or MDCOs, which I mentioned earlier, but also nurse practitioners, clinical nurse specialists, physician's assistants. These are all of those entities that can order that original face-to-face or can conduct that original face-to-face and order the sleep study. And then I mentioned the standard written order. Medicare has gone away from calling it a detailed written order or written order prior to delivery. The only order we currently have is what's called a standard written order. And it consists of six elements. It has to have the beneficiary's name or their MBI. It has to have an order date and it has to have the general description of the item. In addition to that quantity, if applicable, in your case, one oral appliance is all that would be covered, so it doesn't really need to list the quantity. The treating practitioner's name or their MPI needs to be on the form and then their signature. Note that there is not a requirement for a practitioner's signature date. There has to be a date somewhere on the order, but the signature itself does not have to be dated. And then as far as defining the EO486, this is probably the place that you've had the most experience in learning about it is that that device has to be coded by the pricing data analysis contractor referred to as the PDAC. It is classified by Medicare as inexpensive and routinely purchased. I don't know that it's necessarily an expensive item, but that's how Medicare classifies. There are different categories for different items provided through Medicare, and this one happens to fall in that category. We also provide the web address for the PDAC for those of you who are unfamiliar with it. For Medicare purposes, we're a little, maybe you could say behind the times. I don't know or not. I'm not a dentist, so I'm not going to judge, but we do require a fixed mechanical hinge, and we require that it be able to protrude the beneficiary's mandible beyond the front teeth and be able to be adjusted. That mechanism has to allow the mandible to be easily advanced by the beneficiary themselves in increments of one millimeter or less. It has to retain that adjustment setting when removed and maintain the adjusted open mouth position during sleep. And the, well, we had an extra and, but I don't think it transitions to the next slide. So those are the basics about what the Medicare requirements are, and there are specific manufacturers and specific types of devices that meet those requirements, and you will see them on the PDAC with the coding of the E0486. Reminders for that initial consultation, sorry. It's not billable to the DME MAC. All services provided for that oral appliance is incorporated in the fee that the DME MAC pays for the device itself. We can't really discuss any other evaluation codes because those would be potentially billed to Part B, which has very limited scope for their payment. But what we're here to talk about is just the DME portion. And I already talked about the dentist being considered the DME supplier, not the ordering practitioners. And then again, all services included in that oral appliances. All follow-up care during the first 90 days is also included. And again, as I just mentioned, there's no coverage for anything beyond that under the DME benefit. I'm gonna turn this over for a couple of minutes, and Angie's just gonna share a few things about the appeals process so that you can all get a little insight into that, and then we'll get into our questions. So Angie, take it away. Thank you, Cindy. Hi, this is Angie Cooper with CGS. And just to talk a little bit about the reopenings process, this is outside of the appeals process. So with the reopening, you will still have your appeal rights for the claim, but a reopening is there to correct just simple mistakes that may have caused your claim to pay incorrectly or to have denied. And one of the main things I can think of would be just mis-keying the billed amount. So if you mis-keyed the billed amount and it caused your... Medicare will never pay more than the billed amount, so even if we could have allowed more. So if you need to correct the billed amount, if you transpose some numbers, things like that, you have one year from the date on your remittance advice to request a reopening. And so there's different ways you can request the reopenings with the contractors. There is a reopening request form. I believe Meridian as well as CGS will allow you to submit that through their portals. There are ways that you can correct claims through the portals, but that's all done through the reopening process. Okay, and next slide. So there are five levels of appeal. The first one is the redetermination. Information about how to submit a redetermination will be found on your remittance advice because that is the first level of an appeal. You cannot skip a level, so you do have to follow each level of appeal and progress through those levels. And at each level, you will be given information about how to proceed to the next level. So if you request a redetermination and you're not happy with the decision that was reached with that first level of an appeal, that letter will explain to you how to proceed to a reconsideration. And the same thing will happen after the reconsideration. So that's kind of how the five levels of appeal. So, and it will progress through a reconsideration and the administrative law judge, then it'll go into the departmental appeals board and then federal court. And there are specific guidelines. There's dollar thresholds that must be reached for some of these levels beyond the redetermination. And so, see if you'll advance the next slide. And then this just shows you who is responsible for those appeal levels. So the DME MAC, CGS and Meridian, we will handle the first level, the redetermination. After that, it is out of our hands. It will proceed to different contractors. So the QUIC, the quality, I've gone blank on what that acronym stands for. So do you remember what it's called, the QUIC? I know it's Maximus, but excuse me, they do the next level, the reconsiderations. And then, so I'm not gonna read the whole slide to you, but it proceeds after that. All right, and then the next slide. And then here we have our contact information, our websites for all four of the jurisdictions along with contact center phone numbers. You need to call customer service. There are unique phone numbers for each of the jurisdictions. So make sure that your beneficiary, that you've called the right jurisdiction for the permanent address of your beneficiary. Because with durable medical equipment, the claims jurisdiction is based on the permanent address of the beneficiary and not where your practice is actually located. I know I'm on the border of Texas and Oklahoma. So we do have, fortunately, they're within the same jurisdiction, but if you are in one of those border states, you may have to deal with several jurisdictions. Great, thank you. Oh, I'm sorry. Oh, that's okay. We do have a couple more resources here. So the Processing Data Analysis Contractor, the PDAC, it's actually Palmetto is the contractor. They actually review products and they assigned and will review the product and determine that it can be coded a certain HCPCS code. So they handle all of those coding questions. The National Supplier Clearinghouse, they handle Medicare enrollment as a DME supplier. So it's a centralized clearinghouse. One contractor handles all of the enrollment with the DME MACs for the entire nation. So their contact information is listed there. CEDI, they handle all of the electronic data interchange for all four jurisdictions. So if you've got an issue with processing a claim or getting the claim to the DME MACs, the CEDI, the Centralized Electronic Data Interchange, they handle all of those issues. Okay. And I'm not sure if we have another slide after this one. Oh, there we are. Now I'm finished. Thank you so much. Thank you, Angie and thank you, Cindy. So now we can start the Q&A portion of this webinar. And if any audience member has a question to ask the panel and they're using the full screen mode, you will need to exit full screen to access the Ask button to submit a question. I'll be asking the questions from the top down. So please make sure to use the upvote feature to move your favorite questions up the list. Also, in some instances, your question may be answered by a moderator in writing, in which case you will see a notice under your question with the phrase, tap to see moderator's answers. And let's look at the questions now. Okay. So the question first, what are the advantages and disadvantages to being in network with commercial insurances? I guess I'll take this one. The first thing that I would tell you as far as whether or not you're considering to be in network or not in network is you should know your geographical area and what the other dentist in your area are doing or are not doing. And then the next question is how much do you want to do? What is your goal with treating sleep apnea? What is your capacity to treat sleep apnea? Those are probably the first factors in deciding whether or not you want to be in network. Because if no one in your area is in network, there's probably really no advantage to do so. The advantages of in network is the authorization process tends to be simpler because you're already in network. So you don't have to request a gap exception. Physicians appreciate if you're in network. So it's a great establishing a relationship with your physicians is promoting that you're in network. The disadvantage to being in network is your reimbursements tend to be lower with some of the carriers and you can't do anything about it. So you're kind of stuck there, but those are probably the key points. But I always tell people you need to know what's happening in your area. Alex, what would you add to that? I think that's, I mean, those are the biggest ones. I would highlight, as you said, it's easier to get your claims processed or deal with the pre-op stage, both because you don't have to worry about, I mean, even if you want to do gaps, but you don't have to worry about any of that stage, but also some of the commercial payers, a lot of them, I would say, restrict access to their online portals based off of network status. And so depending, and different states have different laws, and so it's all gonna be specific to your state, but like in Virginia, where I am, the state law says that insurance has to make available a phone number for everyone to call, but not necessarily an online portal. And so I know like, for example, Aetna, we can't use their online portal because we aren't in their network. And those portals really are handy. I mean, I absolutely love those portals for basically speeding up what you need to do. So I mean, that's by far, I think, the large one. And the other one to add is, as you said, physicians appreciate it. The model I like to look at, or the picture is, your physicians are in a giant pit in the middle of the Amazon fighting a tiger, and you're standing up on ledge with a ladder asking them to help you when you're out of network. And they've got to deal with it. I mean, it's very hard to be a physician out of network. So the majority of your physicians are in network. And certainly there is a appreciation that even you are willing to kind of dive into that world that they know you don't need to, but you've got their back and you're gonna help them out. So I know that's our biggest practice builder is being in network by far. Yeah. Okay. Thank you. So question, next question. What is the best way to find out if a policy covers oral appliances? Hello? Yep. Best way, phone call. That's the best way to know you're correct. Yeah. Phone call with a reference number. Always with a reference number. Record your calls, get a reference number. Realistically, most online portals and Google search will answer that. But if you want to be sure, phone call. Absolutely, because some of the policies will have some exclusions by employer that may show up as it being covered, and then as you dig a little deeper, you find out that it's not. I will say in our area, it has been a long time since I have seen it not being covered, but I always double check because I don't want to find out on the backside. And this is one of those asterisks of exceptions apply. So in general, and this is a very, very specific way I'm saying this. In general, every plan, you will likely be able to have cover in oral appliance eventually. What that means is if the plan, even if it has an exclusion, a lot of times you can get around that exclusion if you want to go through all of the work of fighting for an exception to policy. And that's because insurances do have to take care of their patients. So if the patient has failed the first-line therapy and the insurance allows no second-line therapy, that can be, usually in most states, something you can fight. It's a long slog and it's not necessarily fun. And that's why I say sometimes it's better just to do the cash route in those cases and not do that fight because it wasn't your insurance that you selected. It was your patient's insurance. And unfortunately, some insurances are just bad and it just is. But a lot of times you can get around absolute exceptions, but you need solid data, failed CPAP trials, not just, I don't want a CPAP. I mean, failed CPAP trials, moderate to severe disease, and support. So it's often not worth it in those cases. Right. Okay. Thank you. I'm new to DSM and only starting a few cases a month. Should I use a billing service? I would say no because what I found from talking to people is even if you used a billing service, you're still contacting the billing service to find out where things are at, how things are being done. So it doesn't eliminate your involvement as much as you would like to because you'd like things to be done in a timely manner. If you're only doing a few cases in a month, it's very manageable for you to do this yourself. Absolutely easily doable. You just need to set some time aside for a staff member to jump through the hoops. I encourage people when they start into sleep medicine to always start with treating someone in your family or your staff's family members. And what a better way to make those phone calls and try those out on people that are forgiving if you make mistakes. So that's what I encourage people to do is start off that way. So you can make the phone calls, find out the benefits, learn the process. When I call people on the phone, if you're nice, most of the time, you'll get a lot of help. So if you're like, I don't know what I'm doing, how does this work? Then they tend to be pretty helpful in directing you along. And after you kind of get your sea legs going, it does become easier. The other thing that I always tell people is when you're calling an insurance company, customer service line, you're calling for a set of specific codes. The E0486, maybe an exam and an X-ray. And that's all you're doing. Those representatives are dealing with thousands of codes every day. And so you have to kind of guide them to get to the answers that you want because this is what you know. It's all you're dealing with. So just be nice and kind of ask the questions and guide them to where you want them to go. And then you'll get the answers that you need, but it's very easily done in your office. You don't have to hire a billing company by any stretch. Yeah. The one thing I will highlight, if you do use a billing company and 99% of the time, you're going to be fine with a billing company, but as Ronald Reagan taught us, trust but verify. Billing companies, at the end of the day, you've given them the ability to bill on your behalf. You have a signed document where you've said, you can submit my claims for me. That doesn't mean necessarily they're going to submit it legally. Again, most of the time they do, the overwhelming majority of the time they do, but always look at your EOBs you're getting and your ERAs and confirm. For example, again, this is a horror story, not the norm. One of the first practices I worked in, I was brought in to help them with their dental sleep medicine program. And the billing service they were using was billing Medicare double the fee that they were billing commercial companies. This is called Medicare insurance fraud and you can go to jail for it. And they are doing it with the doctor's signature on the claim form because they would have the doctor send a blank claim with the doctor's physical signature on it. Never do that, first of all, there's no reason to, they can easily submit the claim form with a signature on file line. But when you sign it, now you've essentially taken all the liability on yourself and the billing company can simply say, well, we didn't bill it, he signed it, he billed it. So you lose some of that protection. So just be careful, there are certainly schemes out there, but again, the overwhelming majority are good. That is an exception to the norm, but always double check that, see what they're doing. Okay, thank you. Next, can you provide strategies for getting in network with commercial insurance? Are the reimbursements worth the effort? Well, it depends. You, again, you have to know what your cost is to provide the service to your patient. What are your lab fees? What kind of time? All of those things factor into your cost. Our reimbursements from commercial payers vary pretty significantly. So it's one of them, I would say no, the other ones I'd say absolutely. To be able to provide that benefit to your patient, you need to know what those amounts are prior to agreeing to be in network. I wish there was an easy answer on the I wanna be in network question. You call member services and ask to contact the provider service representative and they'll direct you. But it's always an interesting caveat because they're gonna hear a dentist and they're gonna say we're closed. And then you're not a dentist in this situation. You're a durable medical equipment provider. And it's a pretty long and lengthy process to get them to understand what it is you're looking for. So persistence is definitely important. We've had one of our easiest cases where we've had a patient come in and we've had one of our easiest contracts come through on a peer-to-peer review. We said, we've done about 20 peer-to-peer reviews and boy, we'd sure just love to be in network with y'all so we don't have to waste your time and our time. And next thing you know, we had a contract and it was amazing and simplest thing I've ever done. And then I had another payer, it took me almost two years. So there is no magic bullet, it's persistence. You can hire some third-party companies that will try and navigate that for you but it will also take your persistence to stay on top of them to get that process gone through because it does, just because you hire them doesn't mean you're their top priority and they're working on it constantly. Cindy, you're smiling. Why are you smiling? Because you hit the nail on the head regardless. Yeah, yep. It's a game, unfortunately, it's a game. And as Alex alluded, the rules change frequently. You're not notified a lot of the times if the rules have changed. So it's just, you have to be persistent and focused on the same type of things. And one thing we say here too at Medicare, one thing you'll run into, I think Belinda could attest to this, is that a lot of insurance companies will say, we follow Medicare guidelines. And they do until they don't. So they don't have to. So that can get you cross ways too because you think they're following Medicare guidelines, which frankly we publish and are pretty straightforward about it. But they do it until they don't. The thing that I find as a safeguard though is Medicare is very specific in their requirements and their rules. And if you tend to pretend that everyone has Medicare and you have all of those things, it does tend to go better even though some of them don't require all of those things. I mean, that's how we operate in our office is that we treat everyone as if they're having Medicare so we have all the documentation and everything in order. Well, that's nice to hear. Yeah, you guys make it easy. Oh, good. Why don't we mix it up with a Medicare question? Oh, stop. Doing great. Not that Alex has stepped out. We should do a Medicare question. Maya, I think you need to unmute. Okay. Maya is having some technical difficulty. Let me just ask a Medicare question while she sorts that out. This is a Medicare question now. How can I bill medicine for the initial evaluation, say a 99204 and for follow-up appointments, 91 plus days after appliance delivery? So you were going into the EM coding there with that question. Cindy? I'll start, this is Cindy, I'll start and Angie can chime in. You can't bill any E&M codes to the DME MAC. So that is a Part B question. Dental services are very limited under Medicare Part B. So your success in that arena for an E&M evaluation, I suspect would not be large. But we at the DME MACs are unable to address those. All of the services that you provide for the oral appliance, the only thing that is billable to the DME MAC is the E0486 itself. All of those additional evaluation services are rolled up into that reimbursement. Angie, anything to add? No, I don't have anything. We really can't answer anything regarding the E&M code. It's only the oral appliances that we would be able to provide any guidance on how to bill. All right, I'm gonna stay with the Medicare team for a moment. Is there a formal mechanism to contest the Medicare allowable charge? And this person also adds that they're in jurisdiction C. So which of you is in jurisdiction C? That would be me. So there's not a fee schedule for the E0486 procedure code. It is based on gap filling. So those claims are stopped, they're looked at and based on the information submitted with the claim they're priced. So you do have appeal rights on your claim when the claim is processed. If you disagree with the allowed amount, you can follow the instructions on the remittance advice and submit a redetermination request with your documentation to justify the allowed amount that you feel it should receive. So that would be your mechanism for protesting that allowed amount. Thank you. Okay, I have one more Medicare question and then I think I'll be able to hand it back over to Maya. But you guys are on a roll. So let's go one more. Does the CPAP intolerance affidavit that a patient fills out in my office establish Medicare's noncompliance with CPAP? This is Cindy, I'll start again. We'll just hand them back and forth. No, there has to be a clinical reason discussed with the treating practitioner, the MD, the DO, the MP, the PA, who is treating the OSA. There has to be medical records in whatever their standard recording practices are to indicate that the beneficiary can't tolerate the CPAP and needs to move to an oral appliance. Thank you. Okay. All right, can everyone hear me now? Okay, great. Okay, so the question, how can I determine if I'm allowed to balance bill? Well, for the commercial policies, it would be in that medical policy that you've looked up is your first thing. You certainly can ask that question when you make that benefit call, if you're allowed to balance bill. But typically, if you do not have a contract with an insurance carrier, then you typically are allowed to balance bill. There are always, as Alex said, some exceptions to that rule, but those are where you would find that information would be in the medical policy that they put forth and then in that benefit phone call. And again, on any benefit phone calls, I would always get the name of the person you're talking to and the reference number, because there's been multiple times that we've had to go back and say, that is not what you told us, and we've had them pull calls. So always get that reference number. Alex, do you have anything to add on that about balance billing? How do you know if you can balance bill? Yeah, I mean, it's gonna be, that's a tough question and state laws, individual will apply. Federally, we're fairly safe still now. There are some federal laws that came out limiting balance billing it from a hospital perspective. Outpatient hasn't really been targeted yet for that, but I would expect it soon or sooner rather than later. But realistically, state law is gonna prevail. I'll be honest, I'm in network, so I don't really pay too much attention to that. But certainly in general, in general, in general, you can balance bill if you're out of network. In a commercial setting, Medicare gets even more complicated because Part B has different rules than Part B DME, as far as balance billing is concerned and limiting charges. So it gets a little more confusing there. I would certainly encourage you on the Medicare side not to balance bill unless you are very confident on the rules, because again, they are very different between Part B where there's a federally mandated limiting charge and DME where it's variable. Okay. What is the best strategy to negotiate a higher fee with a commercial third-party payer as a e-network provider? Best strategy or best legal strategy? I think the right alcohol sends the right person, probably the good to know. Of course I'm not advising that. I haven't figured that one out yet. No. I've heard stories a hundred different ways. Like I think all things in life, it's who you get when you get them on the phone and who's working with you and how much they're willing to work to help your patients. The best I've found is we have this antagonistic relationship with insurances. And in some sense, it's there intentionally. It's to help keep healthcare costs low. There should be antagonistic relationship between the payer and the biller. But I also like to think that there's a human on the other end most of the time. And humans do like to, in general, help other humans if you can give them a good persuasive argument. So I have had some insurances increase our fees. When we highlight, for example, to throw PEDAC under the bus for a little bit, they have some sleep appliances that I, are maybe not the same quality as other devices on the PEDAC list. As far as long-term reliability, not necessarily reliability, but quality of the appliance. I mean, there's just some good appliances on that list and there's some really useful appliances that are not good necessarily on that list. And sometimes with insurances highlighting maybe, hey, listen, Medicare will cover this appliance that cost me $20 to buy. And it will also cover this appliance which cost me 500 to buy. Do you want me to give the $20 appliance to your patients? Because I don't want to, but what you're reimbursing me is giving me only that option. And I think talking to medical directors, showing them what an acceptable appliance is per Medicare standard, because that's the only standard that's universal through the US. I'm not trying to throw Medicare under the bus. It's just, it's a universal standard. Can be eyeopening to them. Because I think sometimes they think that, again, that slide I showed of what insurances think of us, I think sometimes they assume we're just money grubbing, trying to eke every penny out and shysters. And it's not that. Obviously we care about our patients. We want to provide good quality care. So that's the best I've found. But it's, I mean, it's an 80% of the time it's useless. I mean, that's a swing and a miss 80% of the time. It's rare that that connects. I mean, if you can get inside the inner circle to have those conversations, it's helpful, but it's very hard to do. I've never been able to successfully get inside that circle. We have a corporate office here for one insurance carrier and I took a stack of charts there thinking I was going to get to talk to someone, waited in the lobby. And after about an hour and a half, they just asked me to leave. So it's really kind of tough. If you have a physician, a medical physician that is a bit advocate, that might be beneficial. But again, they have to have some access to that inner circle. So it's not easy to do. It's not easy at all. I know the ADSM is working on trying to establish some of that on our behalf as members and they're struggling with it. But yes, I think that that's probably going to be our best bet. Yeah, the other thing to highlight too that I didn't a second ago I should have is a lot of insurances won't negotiate fees that much when you're in your initial contracting stage or your first round of contract. They're more likely to come to the table after you've completed the initial term. So a lot of contracts will have a two to three year term to start and then they renew year to year. And a lot of times if you get to the end of that two year term, you'll be able to get more done. They certainly seem to negotiate more at the renegotiation stage there. Okay, move to question. The next question, do most offices do their own billing after being in practice a while? And what would you deem reasonable for medical billing fees? Ooh, I think zero is reasonable because if you're heavily involved and you're keeping your profit margin as tight as you can so that you're giving an affordable quality device to your patients, any of that that you give away to a billing company is making that you're probably having to raise your fees. Again, as I said earlier, medical billing sounds very intimidating to dentists but it is really not. It's just a matter of getting your feet wet and doing it. It's pretty straightforward. It's pretty easy. You have to make sure you have the documentation to support what you're charging or what you're billing. But once you know what that is, the actual billing is not difficult at all. Yeah. Yeah. And I apologize, I was distracted for a minute there. The question was about reasonable fee for billing company, is that? Yes, I think so. I shop around and look to the medical side as well. So a lot of medical health records have a billing service integrated with their health record. And many times you can get the health record itself, the EHR practice management suite, software suite and the medical billing component where they will bill on your behalf, process your claims, do the follow-up with the patient, the whole revenue cycle management for less than some of the standalone billing companies will request. Typically single digit percentage of claims, three to 6% of claims would be a reasonable thing that I would expect on the medical side, just for reference. And it's gonna depend on volume as everything. If you're doing five claims a month, you're gonna have to pay more. When you're in my practice, since we're only dental sleep medicine, we're billing 30 to 70 E0486 as a month. So I mean, your billing service gets paid as a percentage and they get a whole lot more percentage out of an E0486 than they do a 99213. So if you're doing a lot of 213s, they're making pennies. If you're doing a lot of E0486s, they're making money. Like any business, they're gonna price you based off of how much money they're gonna make. So the more volume due, the lower the cost. Correct. Okay, so Medicare question. If I'm not a Medicare provider and have not opted out, can I use ABNs to treat Medicare patients? Sorry, okay, I was trying to find the mute button. So if you have not enrolled in Medicare, you can do an ABN. That is one of the situations of, you will not be able to charge the beneficiary unless you have provided an ABN to the beneficiary. If you're not enrolled in Medicare and you're not opted out. Okay. Can I add a follow-up question to that? Well, I was also gonna say something. So go, Alex. Is there, so physicians and dentists, no, dentists' mandatory opt-out was paused. Physicians have a mandatory opt-out requirement or mandatory acceptance of Medicare unless they opt out. Do DME companies have that? No. Okay. Yeah, that's one of the weird ones where we've got feet in both waters. So it's certainly an odd one for us to manage. Yes, I used to work for an AB contractor and there is a difference in that there is not a limiting charge on the billed amount for a DME item. If you file an assigned claim, you are limited to the allowed amount. But if you file a non-assigned claim, then you can charge your fee. There's not a limiting charge. And then the enrollment rules are a little different as well. Although I think, Angie, I'm gonna ask you to clarify on that non-limiting charge because is there not a little caveat about your cash fee and the Medicare fee? That could fall into your supplier standards areas. As far as the DME MAT goes, we're not looking at that. So I don't really have a whole lot of information on that as far as handling any inquiries about what might happen if an investigation goes into looking at your practice and how you're charging. If they're looking at waiving co-insurances and things like that, that's usually handled through the UPIC. But we don't have strictly, as far as your billing is concerned, there's not a limiting charge with the DME MAT. Now, if you provide an advanced beneficiary notice, you do have to give the beneficiary a reasonable idea of what you will charge them. And if there is a big difference between what they agree to be financially responsible for and then you turn around and bill them a whole lot more, that could also be an issue there. But typically that type of investigation would not be handled through the DME MAT. Then you're in big trouble. About that. I was just gonna say those kinds of investigations get done by the fraud contractors. So that's usually a word that frightens everyone. So, yeah. And then the district attorney gets involved. Or the federal attorney. Okay. Okay. So next is still a Medicare question. If a patient has a more severe level of OSA, the physician would often use both a PEP and oral device. The oral device allows lower, more comfortable pressure to improve PEP compliance. Will Medicare pay for both therapies in this situation? On my turn, I guess. So this is Cindy. And I never say never. Ultimately, you will be denied initially if there were to... If a beneficiary is on a PEP device and an oral appliance is provided. Angie and I just talked about this earlier today. Both of our systems are set to deny that second device within the five-year reasonable useful lifetime. It comes back to clinical documentation. And you would have to go through that appeals process that Angie talked about. I'm not sure that they would pay both, but then I'm not the clinician that's going to review a claim. So, like I said, I never say never. However, it is somewhat doubtful that both... Because they're both treating OSA, it's doubtful that in the appeals process, you're going to get claims payment for a second device to treat the same thing at the same time. But again, I think you're going to be a long way into the appeals process. And potentially ALJ, the departmental appeals board and beyond and got to think about the overhead that it would take to provide that and go through that process. Now, you're still able to do that, even if you... Oops. Where'd Cindy go? In the middle of the huge pearl of knowledge there. Yeah, and... I don't know that I can finish her thought, but you do have the appeals process. So, that would be something to consider is how much is that overhead going to be if you have to pursue that, especially with the... There are amounts in controversy that have to be met before on each of those levels. And I was just about to pull that up to give you an idea of what that is. If you don't know it off the top of your head. So, and it's not easily on this page that I was going to look at it. They change, Medicare, everything changes quite often. So, I have purged the amount in controversy information from my brain. Would it not be correct? And I'll ask this for our guests on the call that if a patient's got an oral appliance and the follow-up sleep study showed that the oral appliance was not effective and that was well-documented, then would you be able to get Medicare to go back and pay for the CPAP? If there was a change in condition or... Yeah, it just... It's going to be very specific to what's in that documentation for that patient. As far as going back, typically that sleep study, they're looking at the sleep study that goes into determining that the criteria was met on the item. So, you're saying that if they had the oral appliance, would we go back and cover a CPAP if the oral appliance showed not to be effective for the patient? Well, there's not a compliance timeline for the oral appliance. I don't know. I've never seen that before. We could take that back and follow up, but it would deny for same or similar. It would have to be handled on an appeal. I'm not sure exactly what they would have to look at on the documentation to see what that coverage criteria would be. Yeah, I would have to take that back. Is that a hypothetical question or has that happened? That's going to be what the medical directors will ask. The nice thing that DME companies do have that are servicing the CPAP is in that scenario, they're going to be renting the path. So they are going to get a couple months to find out if it's going to charge and what the denials are going to look like as opposed to the dentist where when we're going from CPAP to appliance, it's a larger hit. Now, I'm not saying go after the DME companies and just make them have to deal with it, but my point is in our practice, we've had that happen a few times where we've had a patient go to CPAP and there didn't seem to be an issue. Now, obviously, we aren't asking the patient, hey, did your DME company yell at you? But years later, they're still using their CPAP. So either the DME company gave it to them for free or the DME company got paid. Okay, we'll move to the next question. Can I offer a discount to my normal fee for paying cash? So the big caveat on this is that this is legal advice that is going to be what you need for this, and certainly none of us on here can offer you legal advice. Every state has their own laws. I know I say it a hundred times, but it is state by state. This is my general understanding as a safe method to do this, which is as a same day paid discount that is offered to, because in general, my understanding of this is that all discounts must be offered to any, regardless of paying payment source. So in other words, you can't charge your patient more depending who's going to pay it, if it's out of their pocket or an insurance pocket. So you can offer a same day payment discount. Insurances are certainly offered that same discount. I've yet to have an insurance company pay me the same day that I render the service. And so if you offer that discount to your patient for paying the same day, it's not a cash discount. It is a same day service discount, because you're offering that discount. It has to be reasonable. So you can't offer a 70% discount if you pay the same day. From what we've evaluated in our own research on this, we found that 20 to 30% is reasonable. Above 30, you're going to have to give a really good explanation. That's my non-expert lay knowledge from experience. I was trying to allude and I didn't really get the answer. I was always under the impression that whatever that cash fee is that you have for the early discount, it could not be below what you are billing Medicare. And that's why I was trying to ask Cindy earlier, and I don't know if she got that, but I was always under the impression that none of your fees could be below what you're charging Medicare. Is that true, Angie? Okay, I'm not sure that I understand. So your fee can't... So if I charge Medicare, I'm going to use made up numbers, because clearly we're not supposed to discuss fees. But if I charge Medicare for my E0486, $800, and with my commercial patient or cash patient, I have the $800 for the E0486, but I also have an exam and x-rays. So my total fee was $1,000. And then I said, well, you're going to go ahead and pay me ahead of time. So I will therefore give you an early payment discount of $300, which would make it $700. I was always told that was a no-no, that I should not be below my Medicare billed amount. We're not going to be able to answer that question. That wouldn't be something that a Medicare contractor would be either investigating or tracking. Now, the UPIC, which is the Unified Program Integrity Contractor, they are the ones that hire the FBI investigators. They might look into that. But that's not anything that Medicare as a DMV MAC, we're looking at documentation, we're looking at medical necessity for the device, we're looking at things like that. That is what our responsibility is for. We're not looking to see about what you're charging, even though we can give the blanket statement, you can't waive co-insurance, you can't waive deductible, things like that. That's not our expertise. That's not what the DMV MACs are looking at. The caveat, for example, on that example is you cannot routinely waive those fees. You can for financial hardships that are documented and exceptional. All your patients can't have financial hardships. They can't pay every single bill in two days and somehow can't pay your appliance bill. It does have to be an understandable documented financial hardship and things like that. A lot of times, what we will say is seek the advice of an attorney who is knowledgeable in healthcare. In your state. Those payment questions are always going to be, realistically, none of us can give you the right answer because there is no right answer. There's, as all attorneys do, an evaluation of your exposure to risk and harm and determining how much exposure you're willing to take. I always tell everyone, I don't look good in orange. I don't like to take a lot of risk. Orange is not a good. Clearly, Angie can wear orange well, but I do not. It's actually red, but although I do have orange. Thanks to the Zoom callers. All right. Can we move to the next question? Should I use my type two NPI for all billing to insurance companies? It depends on which box on the claim form, you're putting that type two NPI and where you're putting your type one NPI. We're getting into the weeds here, but you can bill, you should be, okay, so on the claim form, I'm not even trying to guess, I think it's box 23, but it's been a while since I've looked at the claim form. You're going to list the billing provider's NPI. The rendering provider's NPI is going to go on the claim line itself or the line item for what you billed. And the referring or ordering physician's NPI is also going to go on there. So you're going to have three NPIs. On the Medicare side, it's, and please correct me if I'm wrong on this, but you will technically be billing, you have to have a, oh, shoot, now I can't think of it. Well, this is part B actually, because yeah, on the DME side, it's your practice is the DME servicer and the rendering provider, but on the part B side, you're going to have a, not reciprocity agreement, but an agreement between your personal PTAN under your type one NPI and your practice PTAN under the type two NPI, an agreement that practice may receive the funds that are slated to you, because Medicare requires all billing to go through. The physician is the one that's allowed to bill, and then you can allow that fund to go to your practice. So you're going to have a, not reciprocity agreement, but an agreement between physician is the one that's allowed to bill, and then you can allow that fund to go to your practice NPI, and they will then be listed as the billing NPI. On the DME side, I do believe what everything goes through is the type two NPI, is that correct? The practice is the rendering provider, not the dentist. It's the supplier, the PTAN is issued through the National Supplier Clearinghouse. Yeah. I'm not sure. That's tied to your type two NPI. Type two is organizational NPI. I guess to define that, type two is your organizational NPI, type one NPI is an individual practitioner's NPI. And for DME in Medicare, the practice is the supplier. For commercial, it's going to be specific to each commercial insurance, but most commercial insurances are going to require the type one provider NPI to be listed as rendering provider, I believe. With a large asterisk. I'm going to go back to it depends. It depends. In our practice in particular, we have an individual for the doctor, we have a type two for the facility, and when I did my Medicare application, we just did a whole nother NPI, so there would be even less confusion, which actually sounds weird, but it is. So we have three NPIs. Some of my private insurances, when I sign contracts, I ask them, what do you want? And they told me what they wanted, and that's what goes on their claim forms. So it just depends is my short answer, which is probably not very helpful. How do I get a network with insurance? Most insurances in Massachusetts wants to be an oral surgeon. Yeah. How much do you want to fight and how much is it worth it? So federally, when the ACA was passed, there is a provision in there that states that insurances can't discriminate based on specialty such as that. So at the federal level, it is enforceable. Now, do you really want to try and sue in federal district court? Most of us are going to answer no. A lot of states also have laws protecting that. Again, do you want to sue Anthem and deal with that? Most of the time, no. I have run across that myself with many insurances. I have a little advantage because of my specialty is not a general dentist. So I can argue from the perspective of I'm a specialist, no different than an oral surgeon, and can kind of make those arguments. Having said that, I have argued as a general dentist prior to kind of moving in the specialty route. And again, it gets in the weeds and you really do have to find the right person at the right end. And a lot of it is squeaky wheel gets the grease. And it's our office manager, within her first month, when we opened our new practice, we hired someone that was incredibly tenacious. And she had calendar notes on her computer to call every single Tuesday at like 8 a.m. and would call without fail. And she would call for three, four, five, six weeks in a row, just get someone new. And if the person didn't seem like they're going to help, hang up, call back. Because sadly, it really is who you get on the other end. But the important thing to highlight here is if the insurance company tells you to simply check the box that you are an oral surgeon on your application, I would not advise you do that because you open yourself up to them coming back and recouping all the claims they paid for you, stating that you lied on your credentialing application. Even though they told you to do it, they aren't held to that because you are the one that signed the credentialing app. So that's the one pitfall I'd highlight is if they tell you to sign up as an oral surgeon and you are not an oral surgeon, do not check that box. I've had people that were successful at checking the oral surgeon box, crossing it out initially next to it and stating that they were whatever specialist or general dentist or whatever you want to write on there. As long as what you're writing, you can justify. And if the insurance process is that way, at least when they pull your credentialing app, you didn't lie to them. But... I, in the beginning, when we were doing this, I had one insurance carrier that was sort of of that mindset. And I was sort of like the tenacious gal that you spoke of. I pulled up the oral surgeon that they would refer to. I pulled out his school that he went to, what the track looked like, what kind of education that he had. Then I put together the whole what the, that time the diplomat status involved. And I actually won that a lot of times, but it was, it was a lot of work. It was a lot of work. Yep. You can also, one thing that you can do there, bringing up, looking at the oral surgeon network, do a gap, see who they tell you they want you to see. It's going to be an oral surgeon at the network usually. Call that oral surgery practice. If you know it and you've got a good relationship with them, you, I mean, obviously just call the oral surgeon themselves, but otherwise you can secret shopper it and call and be, you know, John Smith and you had an oral appliance and insurance sent them to, you know, told you to go see them. And nine times out of 10, they're gonna tell you, we don't do those. If they tell you that, ask them to sign something on letterhead that states that, and then you can send it to the insurance company stating that, you know, you said send to this oral surgeon, but here's their signature saying they don't do this procedure. Insurances are required by law, both federal and almost every state, that if they are a PPO, anything with a network, that they have to allow patients to receive care within that network. And if they have someone, if they have a network gap, they can't deny someone access to the network that's willing to fill that gap, unless they have a valid reason to. But again, these are the legal answer and actually having that happen are two different things. And rarely do any of us want to go to court to try and enforce it. Okay, question, Medicare question. If I'm non-par with Medicare, can I offer a discount to the amount I balance bill? Well, this is Cindy, it's probably my turn. If you're non-participating with Medicare, like Angie said, you can accept the Medicare allowable if you bill non-assigned and you can collect the difference from whatever your charge is and the Medicare allowable from the beneficiary. The thing that you have to be careful about is, we keep talking about sort of these legal avenues, you can't discriminate against the Medicare beneficiary and you want to be in a position I mean, this really is a little outside of our purview because we can tell you, you can do it. But you want to be sure that you're treating Medicare beneficiaries fairly and you have other patients that you could get crossways with, you know, picking and choosing who gets what and who gets this and that and the other thing. So I think from a Medicare perspective, all we can say is that you are allowed, if you are non-participating, to collect the difference between the Medicare allowable and what your charge is, whatever that is, because there is, as Angie said earlier, there is no limiting in the DME world. As far as advising you otherwise, we wouldn't do that. Thank you. I'm going to jump in for a minute. Maya is not available. Do you have to keep the build amount for the EO486 the same for all types of oral appliances? I ask because some oral appliances have a much higher laboratory fee than others. Your usual and customary build amount is what it is for Medicare, but Alex, I'll go to you for what you would do then for commercial insurance. Yeah, so your fee you charge is, again, this is the best answer for you to get this. The safest way is to speak with an attorney that can advise you on some of the non-specific written things. So, for example, fraud is not necessarily defined and so you do have to look at some of those case laws to see can you be charged with a fraud, fraudulent activity. There's not like a federal code of this is fraud and this is not fraud. So, certainly, there's some wiggle room there, but the general thing to remember on a fee schedule is while, yes, you have fees for code, the fee for that code has to be similar in the similar circumstance. And what I mean by that in dentistry, when we create a code in dentistry where we're very specific and detailed on our codes. So, we don't just have a code for filling, right? We have how many surfaces, anterior posterior tooth, what material, and all of that in different codes for each of those. In the medical world, it's more of a broad spectrum on the code that's then tied in also with your diagnosis. The reason I'm going into this long explanation is because, for example, I can bill a different fee for snoring E0486 versus apnea E0486 because we're talking about different medical managements there and different levels of management necessary and different diagnosis codes. So, just because it's not like dentistry where you have to have a single fee for the single code, but it does have to be applied in the same situation each time. So, I can't say I did a cheap appliance here versus an expensive appliance. It's more what's different about that case. So, I'm only managing snoring where I don't need to worry about follow-up sleep studies. I don't need to worry about long-term health effects. I don't need to worry about morbidity, mortality rate, things like that. It's a much easier medical management case, I can bill less. So, it's certainly in the weeds. The best answer to this, in my opinion, just bill the same thing for everything. I mean, you can get the weeds on exceptions, but realistically, just set a fee you're comfortable asking your people to pay. If you aren't comfortable asking someone to pay your fee, then your fee is too high. Thank you. Medicare, what medical billing software are you using for the billing? Can I do handwritten claim and send out to insurance? And which insurance is paid good so I can enroll to be networked? Thanks. Well, I'm not sure what part of that was for Medicare. As far as billing your claim... Sorry, it was my fault. I apologize. It's okay. For Medicare, you can file a paper claim if you're a small, considered a small provider with fewer than 10 employees, or if you file fewer than... What is it? I don't remember what the threshold is of how many claims per year you file to the contractor, but you can file a paper claim if you're considered a small provider and you have the waiver for the electronic claims. You do have to use a specific 1500 claim form with the dropout ink. As far as handwritten, there may be difficulty because everything's automated and those claims are scanned and optically read. So a handwritten claim would probably get kicked out more than likely. And even if you tried it, don't use red ink because in those optical scanners, that goes away. Yes. But I agree with Angie. Mail in the Mac world comes in and it's very restricted. In fact, I don't know about Angie, but I don't even have high enough clearance in Meridian to get into the mail room. It's very restricted. Everything comes in, is scanned, and then we use all of our claim review is through the electronic means. So I would agree. It has to be a specific font or at least a large enough font to be read. And it has to be in black and you're running a huge risk if you were to try to use a paper, a handwritten claim for Medicare. Yes. And there is free software for following your claims to Medicare. So you can file an electronic claim to Medicare. There is a portal on CEDI. So when you enroll in Medicare through the DME Mac, you can also enroll to be an electronic claim submitter. There is a portal on the CEDI's website that will allow you, if you are a small provider, it will allow you to file your claim electronically. You don't even have to download the software or you can download the free software and file electronically for Medicare. Yeah. Commercial payers are again, the same answer we keep giving. So I apologize, but it depends. Most contracts with insurances and most contracts are going to include a provision that you will electronically bill. And that's just in the contract. And so if you're in contract with them, obviously you have to follow the provisions of the contract. Out of network or out of contract with the insurances, states are going to be different. I'm sure. But in general, the 1500 form is the legal form of a claim. So out of network, most states that I've been in will allow you to send a mail in a claim. There are free softwares to fill out the claim form too, that will literally, you put the info in software, it'll tell you to put the claim form in your printer. You hit print and puts it on the right spot. There's zero excuse to handwrite a 1500. In my opinion, there's no excuse not to file electronically either. But in general, having said that, there are times that you do drop claims to paper. So for example, if I'm doing a claim that I know is going to be, let's say I'm billing a miscellaneous code, so it's going to require an attachment, it's going to require that I submit it with a explanation of that, a report of that miscellaneous code, that you'll drop to paper, because there's no way to submit attachment. Many times there's not an easy way to send an attachment electronically with your claim. And so in those cases, you'll drop the paper. So it has to be an exception. But again, there's so many softwares that will do it for free, or five cents a claim. You know, I mean, the cost to send a claim is virtually nothing electronically, and you'll want an electronic because it can't get lost. It can't get lost in the mail, can't get lost. I'm going to guess that's why your mailroom is so secure, because that chain of custody is probably extremely important and has to get, the second that mail is opened, I imagine it has to get the letter. I'm sure the envelope has to get stamped, that what's in the envelope probably has to be stamped on every page, the date it was received. I mean, having gone through the VA system as a vet, I know if I, the second I walked into VA office to write a claim, they had a giant stamp that every page was stamped 20 times and scanned immediately of the risk of stating of loss to the government. And so they do take that very seriously. We do. And it's interesting, because I was previously a DMV supplier, and I always wanted to be a claim when it came into Medicare, because you hear that, you know, papers all over the office and things fly around everywhere, and it gets misplaced. That does not happen. You are absolutely right. The chain of custody, if you will, for that claim information is extremely tight. Okay, good. All right. How do I find out what the e-network benefits would be for the oral appliance? If you're out of network and you're making a benefit call, then I always ask for the in and out of network benefits. There are a few insurance carriers that will not give you in-network benefits if you're not in network. Then my next question would be, do they allow the gap exception, the in for out, network deficiency, those are all terms they use for the same thing, and the answer you hope is yes, then you would have to complete that and then go back and make the benefit call again. But most of them will give you both in and out of network benefits without any issues. Yeah. It's part of your call. As a little caveat, too, to highlight, there is no such thing technically as an in-network rate. And that's because in-network means you're contracted with the insurance, which means it's an individual rate that you contracted them at. Having said that, yes, most insurances have a standard contract rate that they're going to offer everyone that wants a contract with them. But technically speaking, my rate may be different than my partner down the street's rate with the same insurance, both in-network, because I negotiate better or worse than he does. Or I may have a different argument to make than he does. So certainly in-network rates can fluctuate. If you are billing out of network and looking for a gap, I would advise you to ask for what's called a single case agreement. Almost all insurances will do that if you ask for it. And what that is, is that you are entering into a literally what is called a single case binding agreement that you agree to. Generally speaking, you have to agree not to balance bill the patient and the insurance will now predefine a rate for you in that single case. Now, this is different than a multi-plan offer. So as you send claims in, you're going to start getting this fax back from multi-plan saying, look, we can pay you tomorrow if you agree to this rate. If you don't read the fine print, they will share that rate with every insurance company. And now insurances have a notice that you have accepted that low rate and you'll be stuck at that rate until you go through the hurdles it takes to get out of it, which are letters that are sent into the right people at the right times with right signatures on it. So single case agreements are great. It's non-binding across any other case for that exact single case. And you can predefine your benefits. You usually have to ask though for those, but ask. And I also was, since Alex brought up the multi-plan, I will, in the beginning, everybody's scared to say no because it seems like they're not going to pay you at all, but that's not it. If you really read it, you can say deny, you can give them a reason, you can counter back with a price, but you are not obligated to sign that in any way, shape or form. Yep. One trick, if you really want to get back in the insurances, read it carefully. Most of them will say that the insurances has processed your claim or approved your claim and they can help you get your payment faster. If it says that on there, insurance can't deny your claim later. They offered you a payment. You don't have to accept that payment, but they can't come back and deny the claim. And I've had them do that. I've had them deny a claim and I've appealed it saying, no, I had a multi-plan agreement sent to me stating that you've already adjudicated the claim and accepted it. And now we're just negotiating pricing. You can't come back and deny it. And then they've overturned that appeal. So multi-plan in general means that they've accepted the claim and we'll pay it. They're just trying to get you to pay, except lower. And you can usually use that to negotiate a higher rate. Or if they're dumb enough to give you a, I've had this where I've gotten a multi-plan that was like 10% off of our billed charge. You can sure as that, I signed that immediately. Cause now that locked in that multi-plan rate for all the other ones. So if they messed up and give you a really good multi-plan rate, take it. Thank you. Can you explain the same and similar rule and strategies to get patients covered if they have attempted CPAP in the past five years, what documentation is required? So with the same or similar, your claim will deny if you've got a CPAP on file, if the beneficiary received a CPAP within the last five years. So you would have to look at appealing that claim and submit the documentation to demonstrate the medical condition, the change in the medical condition. What you would need to submit with that appeal would be, if you're, you know, appealing that with Medicare, there's a redetermination form that's used that is specific to Noradian or CGS. Make sure to include a copy of the order from their treating practitioner, the proof of delivery, and then your medical records to substantiate the change in that condition. So there would need to be that focused history and examination. If you look in the policy article where it talks about the documentation requirements for the oral appliance, they're going to be looking at a medical record from their treating practitioner that's going to address whatever that condition was that caused the change. They're going to look at their experience with the CPAP, why it's no longer working or no longer appropriate. Just a very clear picture. We always say that the documentation needs to paint a picture of what's going on with that patient, so they'll need to see, you know, exactly what was going on and why that CPAP is no longer appropriate in order for the Medicare trust fund to consider paying for another device to treat that same condition. Thank you. What are the Medicare time limits from the face-to-face evaluation with a physician before a sleep study, to the sleep study, to the delivery of an appliance? And I can repeat the question if you want me to. The time limits. This is Cindy. This is a fairly common question, Maya, so thank you. I think I can get it. So when we talked about the face-to-face, Medicare doesn't have a time frame, quote-unquote per se, between that face-to-face and the sleep study. Obviously, it should be in a reasonable amount of time. We'd like to see that be within, like, three months, but there isn't a specified time frame. Then the sleep, because oftentimes it's difficult to get in for a sleep study, and then there isn't a specified time period between when the sleep study is completed and an item is ordered. However, there is a Medicare requirement that ongoing medical need must be shown within 12 months of any billed date of service. So if you were to get to the point where that sleep study was older than 12 months, the process would have to start over. The sleep study has to be within 12 months of initiation of therapy. Okay. I think there is a similar question down the line about that, but I'll get to that. If I'm out of network with a commercial third-party payer, can I offer a patient a discount to my normal fee? I thought we already answered this. Did we not answer this? No problem. I can move on. Yep. When will Medicare make paying for oral appliance easier when CPAP is tried and failed, currently, for severe OSA patients? This is a huge block. That's a question. Respectfully... Hi, this is Cindy. Oh, yeah, okay. This is Cindy. Yeah, it looks like Angie Speck. We're not trying to make it more difficult. Please understand that it works both ways. If an oral appliance has been tried and the beneficiary has to go to a CPAP, the DMV supplier has the same challenge that you do as an oral appliance provider. That's why the appeals process exists to allow you to show that there's a clinical need for a change. Fortunately or unfortunately, it's the way the DMV program works in that we don't let... You may not appreciate this analogy, but we don't let a patient go from a standard wheelchair to a power mobility device without showing that there's a clinical need. It's just the way the Medicare program works. Again, that's why the appeals process is available. Respectfully, again, to the question and the person who asked it, the challenge I think we often feel as providers about the difficulty of medical policies is, I personally believe, is sometimes a mis... I'm not understanding, but a higher expectation of how it should work. I think we're expecting sometimes these things to be easier than they really should be. I also don't find that what's difficult is having the confidence and comfort that you will make it through the appeal stage. And at the end of the day, that's a decision, again, that your patient has made based off of their insurance. It's not a decision you made in that treatment and should be made in that decision you made in that treatment. And just like dental insurances won't cover a Panerex every year, and certainly they will in circumstances, certain circumstances, but we don't necessarily consider that a hard thing to bill Panerexes every year, because we know the rule is that it's once every five years or once every seven years, unless there's a medical need, and you're going to have to prove the medical need. The one thing that I will definitely agree with on the question, as far as ease, that I do wish Medicare would do better on, and of course, a reminder that the contractors are not Medicare. Medicare is a rule set by the government and bureaucrats, and then the contractors have to enforce them. But the inability to proactively do this is certainly frustrating. Most of our insurances we can submit for predetermination or pre-approvals, and it is frustrating that we can't on Medicare. But having the confidence, I have found that in general, Medicare is my easiest insurance as far as knowing what the rules are and knowing how the rules will be applied. So I've yet to have an issue with Medicare that I didn't go in knowing what the answer would be, and knowing that I just simply had to wait for the forms to be read and the appeals to be read and applied correctly. As opposed to commercial insurance, where good luck, because they can make up 20 rules every minute. Generally, they don't, but they can. But I found that Medicare, the contractors in general, do a fantastic job of, if you fill out the right form, you're good. Now, I'm also coming from a military background, where that's what our everyday life is there. So I'm kind of used to knowing to look up the right form and putting the right things in the right box. But it's frustrating. It's annoying. But I don't personally find it that difficult, other than the comfort of sitting and waiting and knowing it's going to take 90 days to go through all the stages. I'm going to agree. I think that Medicare is very black and white. They're very specific. They lay it out very clearly. They tell you what to do if something happens. There's no gray areas. And that's how I explain it to my patients. They're like, well, can you try? Well, I can't, because you don't meet the criteria. It says right here, see the criteria. I mean, it's very simple. It's very easy. And you're right, commercial payers can decide next week that they've had too many claims. So they're going to change the rules. And that's just, that's, you're kind of at their mercy. Yep. I find that, again, I find Medicare, asked me back when the ACA was being evaluated, and I would have said the single payer was the worst thing on the planet, and it was a dumb idea. Now in today's world, having lived on the other side of the fence of dealing with medical insurance, I love Medicare. I disagree. I don't like when I get paid by Medicare. I don't like some of the hurdles, but boy, it's so nice to just simply know the rules. They apply universally, generally universally. Certainly some MACs will interpret a rule differently than others. But in general, I find Medicare very easy to deal with, as long as you're not expecting to ever talk to a human being. And usually you don't have to. I mean, it's kind of a joke, but it's also true. I don't need to. I don't have to argue things with Medicare. I send them a claim, two weeks later, I get paid. It's great. Thank you. When will there be an update of current devices? There are many devices that fit the requirement, but are not included on the Approach PDAC list. This is Cindy, if you can hear me. As the contractors, we don't have anything to do with that. As Angie mentioned, when she went through the resources, the PDAC is another MAC contract. The government has many contracts, and the PDAC is another MAC contract, and the DME MACs who process claims and provide education don't have anything to do with the coding of those devices. Thank you. And to add, if I can add on to that, PDAC is voluntary. It is a voluntary submission. So PDAC isn't going around looking at every appliance that exists. The manufacturer sends the packet to PDAC and says, we want to be on your list. I would put a lot of money down that if the appliance you want isn't on PDAC list, it's because the manufacturer doesn't want it on PDAC's list. Unless we're talking about an appliance that in no way, shape, or form gets close to fitting criteria. But there are lots of appliances that fit criteria that aren't on PDAC's list, and most of the time, it's because the manufacturer doesn't want it there. So ask your manufacturer, hey, why isn't appliance XYZ on PDAC? See what they tell you. Are repairs paid by Medicare? Yes, this is Angie, and sorry. Yes, repairs are covered by Medicare if it's needed to, you know, bring that device back into working condition so that it meets the coverage criteria. So they are covered when it's necessary to make it serviceable. Just as long as that expense for the repair, it can't exceed the estimated expense for purchasing another item. So we're not going to pay more to repair it than it would have cost to just replace it. Okay. Thank you. Medicare covered study means study paid by Medicare or study which meets Medicare criterias? That's a really good question. This is Cindy, because it has to meet Medicare's criteria. As DME Mac, we wouldn't even know if Medicare paid for it because the study itself gets billed to Part B. We look at, when we evaluate claims, we look at, are the criteria that we went over earlier met in that sleep study? Whether or not the lab bills it to Medicare and get paid for it is between the lab and Part B. Can I ask one caveat? Patients 65 years old, they had the sleep study done when they were 64, not a Medicare beneficiary at 60, assuming normal, not a beneficiary at 64, no disability. That's actually a good question, too, because you can have your sleep study done, prior to your Medicare eligibility, as long as therapy is initiated within those 12 months. Okay. Thank you. How do you access the Medicare portal for SAME and SEM-A-LAR? I'll go first, and Angie can go. Okay, go ahead, Cindy. Because, sorry, because we have different portals. So, for Noridian, you simply would go to the Noridian homepage, and there's a big section that says, Noridian Medicare portal, and you just sign up to utilize the portal. I'm assuming CGS has a similar process, but Angie, I'll let you describe yours. Yes, CGS, you can access the portal from the cgsmedicare.com homepage. You can access the portal from the cgsmedicare.com homepage. There's links all over in multiple places on the page, in case you miss it. Some people's eyes automatically go to the right, upper right corner, some to the upper left corner. So, we've got it in all four corners and in the middle of the page. So, once you access the portal, go through the whole registration process, same or similar can be found in the claims history section of CGS portals, called MyCGS. You would go into your claim preparation tab, look at claims history, and you can do a search based on just the first letter of the HCPCS codes. You would just type in the E with your date range, going back five years, and it would show you all of the codes within the criteria that have been filled. And again, though, you do have to register for each jurisdiction's portal. At Noridian, you don't get access to jurisdiction A if you register in jurisdiction D. You have to register in each jurisdiction. And at least I can only speak to MyCGS, because that's my region. On the MyCGS portal, you do have to highlight, this is a a frustration of mine, you can't look for same or similar. You can look at claim history, and you have to know which HCPCS would be classified as that. So, you would want to look up the HCPCS for CPAP and BIPAP. If you put an E0486, it's going to tell you there are no claims billed. That doesn't mean that CPAP or BIPAP wasn't billed. So, you do have to search each option. Yes, or you can just type the E, and it's going to bring you every HCPCS code that was billed. Exactly. My point is, don't just put in E0486. You've got to look for it all. And the second frustration is, I would advise you to set a calendar notice to log into the portals. Again, I can only speak for MyCGS, although I have a feeling this is federal law, not Max trying to be annoying, that you have to make sure you log in every, what, 45 days or something like that, or you'll go locked every 20 days. Yeah, you have to log in, you have to send a recertification. Someone from your practice that's authorized to, an authorized signer, has to send a recertification every 90 days or something like that, that they still need access to the portal. Not that I would advise you to do this, but if you save that fax form with your signature on it, and just white out the date, and change the date, and have it sent every time it needs to be done, that's certainly a much easier way than refilling out the form each time. But you do have to do that. So it is, that is one of the annoyances of the Medicare portals, is that they are more cumbersome. Well, it is. First thing I do. To the Medicare system. Go ahead, Angie. It is, you're basically accessing the Medicare system, so there's a lot of security involved in that, making sure that we know that, that the CMS knows who is looking at this information. So that's why there's so much security there. You know, that would be disastrous if someone was able to hack into these portals, because that is, you know, Medicare beneficiary identifiers, everything is out there, so. Yep. Go ahead, Cindy. Agreed. And the only other thing I wanted to say, the Neridian portal is slightly different in that we do allow, under option two, to put a code range. So you could do either 486 through either 601, and you would get every code associated with a PAP device.

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