Welcome. I'm Ari Wolfson, the moderator for this evening's webinar on how to approach credentialing with medical insurers. I'm joined with our speaker, Courtney Snow. The AADSM does not endorse any service, products, devices, or appliances. The use, mention, or depiction of any service, product, device, or appliance during this webinar should not be interpreted as an endorsement, recommendation, or preference by the AADSM. Any opinion expressed or communicated regarding any product, device, or appliance during the webinar is solely the opinion of the individual expressing or communicating that opinion, and not that of the AADSM. Whenever possible, presentations should be supported by evidence. In instances where evidence is lacking, speakers have been asked to verbally disclose that their presentation is case-based or based on clinical experiences, that you can use independent clinical judgment to make decisions for your practice and patients. Courtney Snow is well known in the dental sleep medicine arena for her expertise in navigating the complexities of medical insurance reimbursement. Her skills are applied to a spectrum of services performed in dental practices, including oral appliance therapy for obstructive sleep apnea, as well as treatment services for TMJ disorders. She has spent almost 11 years of her career working in an industry-leading software and education company for dentists, and nearly five years with an oral sleep appliance manufacturing company. She has successfully guided practices in overcoming obstacles related to medical coding, billing, and documentation, transforming challenges into triumphs. As a lecturer specializing in medical coding, billing, and documentation, she's not only generously shared her expertise, but also strives to infuse a sense of relatability and enjoyment into the learning experience. Courtney, you can take it away. All right. Thank you so much, Dr. Wolfson, for the beautiful introduction. And, you know, I think when it comes to medical billing, credentialing, we all know it can be tough to make it fun and interesting sometimes, but I will do my very best this evening. So while it might not be the most exciting content in the world, it's extremely important to set your dental sleep medicine practice up for success. So tonight we're talking, or this afternoon, for some of you, we're talking about how to approach credentialing with medical insurers. I do not have any potential conflicts to disclose. And the objections, more objectives, for this presentation is to first understand the difference between credentialing out of network enrollment and in network enrollment, and then how to complete the top three credentialing tasks to achieve medical billing success. So before we dive right in, I think it's important to set the framework that obviously we all recognize the pivotal role that medical insurance plays in successfully implementing dental sleep medicine. So even if you've already learned the basics, the essentials of the billing process, the coding, the billing itself, documentation, credentialing is a separate proactive measure that can save you valuable time in the future. So first things first, let's clarify credentialing out of network enrollment and in network enrollment. What you'll find is that a lot of times these terms get used interchangeably, but they are different. They are definitely not the same. So the important things to know when it comes to credentialing, I consider that a must do when you're working with medical insurance. And we'll talk more about why. Out of network enrollment is something you might need to do. And we'll talk about why you might or might not need to. Now, when it comes to in network enrollment, it's always a choice. Now, starting with credentialing, that's the topic this evening. The very first thing that's important for everybody to know is that the credentialing process alone does not automatically make you in network. And I think this is especially important to be aware of if you are paying a person or a company to perform credentialing or enrollment activities for you. It's important to know what services you're paying for. So credentialing is not network enrollment. It's defined as a formal process that utilizes an established series of guidelines to ensure that patients receive the highest level of care from healthcare professionals. So in order through the credentialing process, a dentist will report information such as contact and practice information, education and training history, any licenses and certifications applicable to your trade, proof of liability insurance, as well as any malpractice history. Now, out of network enrollment, as I mentioned, it's something you may need to do. Not every medical insurance company has a formal process for a provider or a practice to enroll out of network, but some do. You'll find that to be a common theme in medical billing. Not all insurance companies handle these processes the same way. So this screenshot here is a great example from Blue Cross Blue Shield of Illinois as an example where when you are filling out their enrollment forms, you can choose to participate in or out of network. And there are some payers that may not process your claims if they require out of network enrollment if you haven't completed that yet. So just something to be aware of, but please know not every insurance company does this. Some may just want a copy of your W-9 or something more simple like that. Of course, if you are enrolling out of network to be an out of network provider, there is typically no contracted allowed amount for services. So it's just enrolling to be recognized to process claims, basically. Now, the typical processing time when you submit an out of network enrollment is between 30 and 90 days. Now, when we're talking about in-network enrollment, this is a formal process that you're required to go through if you want to be an in-network provider. You'll also hear this referred to as a participating provider or a preferred provider. But of course, the big difference in network, just like with dental insurance, you have a contracted allowed amount for your services. And you're expected to write off any amounts above your allowed amount. You're also contractually required to do other things when you enroll in network. For example, you are required to file claims for covered services, typically, as well as report any changes to your practice or provider information. Things like you have to give notice if you're exiting the contract. And there's typically a certain amount of time you have to give them the heads up that you'd like to exit. Now, this is the part that nobody likes about in-network enrollment is the typical processing time is between four months to who knows. And I'm sure many of you on this session tonight may have run into that over time. We're going to talk a little bit more about in-network enrollment later. But again, tonight, we're focused on credentialing. And let's dive in with the first credentialing task you should complete now if you haven't already. And that is doing an NPI assessment. What do I mean by that? Well, checking the information that is registered to your NPI number or numbers to make sure it's accurate and up to date is extremely important. And I can't tell you how many times over the years that I have seen a provider that hadn't updated any NPI information in a decade. And there's a practice listed that they hadn't worked at for at least five years. And, you know, this is important information to keep up to date because health plans do reference this information. Now, for practice owners, if you don't already have a type 2 NPI, you may consider applying for one if you already have one. Again, check it for updates and make sure it's accurate and up to date. The great news is all of this is free. NPI numbers to apply, to update, they don't cost you anything. Now, how do we get that done? How do we check what's registered to the NPI and get it updated or apply for a new one as needed? So the NPPES registry is the registry I always recommend using. You'll find other NPI registry or NPI lookup sites, but this is the official registry. So the great news is as long as you have the doctor's first name, last name, and then the state, if it's a quite common name that might yield many results, you can find that NPI very quickly and easily. And it will show you all of the information that's currently registered to it. Now, I've mentioned a type 2 NPI. Why do we want it and exactly what is it? So type 2 NPIs, also known as organization or entity NPIs, represent organizations instead of people. So your type 1 NPI, that represents a person, a healthcare provider, and that sticks with a doctor for life. It's kind of like their medical social security number. It sticks with them. But a type 2 NPI, a person, a doctor could be associated with multiple different type 2 organizations, type 2 NPIs throughout their career. Now, why a type 2 NPI? One of the most important things that there are some medical insurers out there that require that you use your type 2 NPI unless you're a sole proprietor. So group practices, this is really important. And I think equally as important is using that type 2 NPI allows the medical insurer to cut the reimbursement checks to the business instead of the individual. So again, instead of having the reimbursement check written directly to a doctor in the practice, it goes to the business and the business pays their doctors how they do. Also, having that type 2 organization, that type 2 or organizational NPI, if your ultimate goal is to enroll in network or for those cases where you may need to enroll as an out-of-network organization or provider, it allows you to roster multiple providers under that type 2. So it makes it go a little quicker to get new providers if you have a provider leave or join. Now, as I mentioned, it is easy to keep this information up to date. I highly recommend completing this online. You can do it on paper. However, online is quick and easy. Any new applications or edits to current information are typically done and approved within 24 hours. It's fantastic. So you will log in with the Identity and Access Management System account, which is your INA account. And that's where you can complete those updates or apply for a new one. Now, if you do want to do the paper route, there is a paper application available on the NPPES homepage that you can snail mail in. That's the only option for submitting that one. So you'll visit the NPPES homepage. And as you can see here, you're going to need to log in with that INA account. If you don't have one, go ahead and create it. It'll be extremely helpful moving forward. If you have one, but you can't get in, make sure you do get the password, username and password recovered. That's usually the most difficult part of the process for the providers that haven't gotten in yet. Beyond that, it's pretty easy is the great news. So for your type one or individual NPI, just a heads up, if you don't have one yet, the required details when you apply for one is your name, social, date of birth, birth state, country, and gender, mailing address, and mailing address, at least one practice location address and phone, at least one taxonomy code, which we'll talk about what that is and why we want it. You'll also be able to put your state license information, your dental license information, and you'll need at least one contact person, name, phone, and email. If you're applying for your type two, for a type two for the first time, the required details are similar, except you'll need the organization name, tax ID, the authorized official, so somebody who is an owner or has managing control, their title, position, and phone, and again, mailing address, practice location, taxonomy code, and a contact person. So be sure you have all that information ready. Now we've talked a lot about taxonomy codes, so let's talk about what they are now. So a taxonomy code is, by definition, a code that describes the provider or organization's type, classification, and the area of specialization. This set, this taxonomy code set, gets updated twice a year, so we're currently on version 24, and there are 874 taxonomy code options. It's a lot. Now, the important thing to know about taxonomy codes is they are associated with NPI numbers, but they're not unique like NPI numbers are, and you'll see what I mean on the next slide. Now, again, whether it's your type one, your personal or individual NPI, or the type two for a business, for an organization, you can have more than one taxonomy code. Up to 15, I believe. You typically don't have that many, but the type one and two NPI taxonomy code sets are slightly different, but again, you just need to have one selected as primary. So good news is I'm not going to make you go through all 874 options. I have listed here the taxonomy codes that are part of the dental providers set of taxonomy codes, and the ones in light blue are ones that I see very, very commonly used in our industry, but of course, be sure that you're selecting the one that most accurately describes your specialization and classification. Now, something that you may, again, for any of you that already have your type two NPI, during the NPI assessment, you'll have the opportunity to add or edit the taxonomy codes that are currently on your NPI. So again, of course, your primary taxonomy code will be a dental practice, a dental, I think they term it clinic, but as a secondary taxonomy, you can consider adding the durable medical equipment and medical supplies taxonomy code. There is one that is a specialization of customized equipment. So I think that one so accurately describes what we do between having the dental clinic as the primary and the DME customized equipment as a secondary. All right, moving right along. So the number two credentialing task to complete now, if you haven't already, is a CAQH assessment. I'm sure everybody has probably maybe heard of CAQH, but you might not know exactly what it is. So this is very important to get filled out if you plan on attempting to enroll with medical insurers and is often the first step of the credentialing process. So it is extremely important. So when I say assessment, I mean, if you're not sure if you have a CAQH profile yet, jump in and find out. And even if you do, definitely check it for updates and make sure that it's as up to date and accurate as possible. Now, something important to know about CAQH is that it's not for individuals, or excuse me, it is only for individuals. It's not for groups. So you'll have a provider profile about you, but you won't, for example, register your organization with CAQH for its own profile. Those organizations will be a part of your profile, but it won't have its own. And again, it's free. So again, so important to be sure CAQH, if you get nothing else out of this webinar, please do your CAQH profile. Because many medical insurers will pull your credentialing information straight from your CAQH profile. So while it might seem like a lot of information to fill out at first, the great news is you just do it once and many insurance companies use it instead of having to do something separate for each one. And as I mentioned, it's often the first step of whether it's out of network enrollment or in network enrollment, or just plain credentialing. You'll see here both Blue Cross Blue Shield of Illinois and Aetna, as examples, state right on their website, that the best way to make sure that your credentialing process goes smoothly is to have your CAQH profile up to date. So how do we get there? Well, the great news is the CAQH and the American Dental Association do have a specific portal for dentists, so they make it quite easy. On the CAQH ProView login, you'll find right under the normal sign in that there is a sign in for dentists right underneath where it says first time here. And that will take you straight to a login page for your ADA profile. And once you're logged in, you're going to find CAQH credentialing under the account option there on the left hand side shown in that third screenshot. Now, this tip is something that your team will thank me for. So my credentialing tip for CAQH is to complete your CAQH, doctors, complete your CAQH profile yourself, or be sure to have all of the information ready for the person or company that's completing it for you. And the reason I say that, there is quite a bit of personal information that goes into completing this profile. So there on the left hand side, you'll see that is all of the different sections that go into your CAQH profile. And the reason I say best to do it yourself, this is all of the information that you're going to need to provide to the CAQH. Again, it's not something that will take you days, but it's not, you're probably not going to knock it out in 30 minutes. Okay, plan on a couple of hours. Because again, there's a lot of personal information that if the person or company that is completing this for you, if they don't have it handy, it very certainly can turn into a very long and drawn out process. And I'm sure just at a glance, you can see why. For your personal information, a lot of things you would expect like name, address, contact info, but they do have things in there such as gender identity, date of birth, and birth city, state, different languages you speak. There is a section for professional IDs, where you'll need to provide your state license information, the number, the issue and expiration date, any, you know, DEA registration information as applicable, any existing Medicare or Medicaid numbers. Also, your education and professional training. So you'll actually need the dental school or any residency, the names, the states, the dates attended, the graduation date, all of that. You'll go on to list any specialties, again, board certifications, any areas of specialized training, any practice locations that you practice at, hospital affiliations as applicable, as well as, again, professional liability insurance information, and all of your employment information. Okay, so all professional employers names, address, the dates that you were employed, reason for departure and eligibility for rehire. And lastly, there is a disclosure that there are going to be several questions related to license and privilege revocation, suspension or denial, any sanctions, different, you know, any disciplinary actions, whether from medical insurers, boards, state or federal agencies, as well as any claims against professional liability insurance and malpractice claims, and of course, any criminal history. So that's all of the information that gets put into the CAQH profile. You'll also upload a few documents when you submit it. Again, you need a copy of that professional liability insurance, DEA is applicable, and the CAQH will provide a standard authorization release form that needs to be signed and uploaded. And depending on your state, you may have an additional state release or authorization form. But again, those two would be provided directly in CAQH. You don't have to go digging for it. Now, important to know about your CAQH profile. Once you get it in there and you get it attested, you must re-attest every at least 120 days. So you can do it more often than that. Anytime you make a change, it makes you re-attest anyway. But a little tip for whether it's, you know, the doctor that is responsible for this re-attestation, or if you've got a practice manager, I like to set a reminder on my calendar about a week out. That way, just in case you've got an expired insurance policy or DEA that needs to be uploaded, you have time to get that uploaded and re-attested in time. Also important in your CAQH profile, there is an option. You'll see there at the bottom of this screenshot for the authorization setting. And so, you can choose to let health plans access this information without you having to manually approve it, or you can choose to manually approve it. Okay, great. Now, the number three credentialing task to complete now, if you haven't already, is an Availity and a NaviNet assessment. Okay. Now, Availity and NaviNet definitely have some fantastic uses in the medical billing process. When it comes, what these two platforms or programs can do is allow you to verify, for example, eligibility and benefits online. Some plans, you can submit prior authorizations, and some insurance companies are adding different provider enrollment and credentialing activities as well. So, while there are a lot of things in Availity and NaviNet that you would use outside of the credentialing process as well. So, even if your intention is to use them for the medical billing side, it can save you a lot, you and your team, a lot of time on the phone with medical insurers. Now, an important thing to know about Availity is that there is a free version and a not free version. So, Availity Essentials is the free version, and it does give you access to several different insurance companies. And again, it won't 100% cut out your time on the phone, but it sure does lessen the time for checking claim status and all of that. So, you will also have to input your business and provider information into Availity and NaviNet, so that information is stored. Now, Availity Essentials Plus is not free, and it does give you access to more insurance companies. So, while the free version, you can still do many of the same activities, just not with as many insurance companies. And same thing for NaviNet. NaviNet Open is the free version, and NaviNet All-Payer Advantage is not free. And again, it just depends on the number of insurance companies that you're able to access. So, once you have registered or signed up for your account, again, whether you choose the free or the paid version, your first step is to register your organization. If your organization has never been in Availity or NaviNet, you need to register the organization, and it will go through a verification process. Sometimes it only takes a couple days, but it could take up to 30. And once that information is registered, you will verify it every so often. So, for the organization and provider registration, you'll have pretty much all of the information you would expect to have ready for that tax ID, NPI, organization name, and if there is a doing business as, you'll need both the legal business name as well as the DBA. Make sure you have the taxonomy that you've selected handy and the service addresses. And for Availity, for example, that business profile, you will verify it every three months. Again, you'll get email reminders, but also something I just like to put a reminder on my calendar so I can check it a week out and see if there's any, you know, updated documents or paperwork that I'm going to need to gather. Now, let's circle back to, I promised we'd talk a little bit about, you know, in and out of network enrollment. So, as I mentioned earlier, when, if you're considering enrolling as an in-network provider for medical insurers, the first thing to know about it is, keep in mind, it is completely optional. You never have to enroll as an in-network provider. However, of course, many providers are interested in that because some patients don't have any out-of-network benefits, right? And unless you are able to obtain a gap exception or a network deficiency request, then a patient with no out-of-network benefits doesn't have any coverage at your office unless you're in-network. And of course, you know, in-network patients, out-of-pocket costs are typically lower and insurance companies are fantastic at training their beneficiaries to seek in-network providers, right? We've all gotten those emails from our insurance company that says, did you know, here's our network providers, check them out. So again, it's always a practice decision whether we want to go down the route of enrolling as an in-network provider. Of course, the downside to an in-network enrollment is, you are going to have a contracted allowed amount, right? So you will be expected to write off any amounts above the allowed amount that the insurance company has set, which again, typically is going to be lower than you would really want to charge. But that's the exchange to be an in-network provider. Now, a quick in-network enrollment tip. Again, if your goal is to go down the in-network enrollment route, enrolling your practice as a Medicare DME supplier for oral appliances for OSA can actually increase your probability of obtaining in-network contracts. Well, why? Some insurance companies offer Medicare Advantage plans, right? And they do like to, you know, see that their in-network providers can service all of their plans that they offer. So again, in-network enrollment is not a requirement. Enrolling as a Medicare DME supplier is also an option, but I'm not going to do a whole presentation on Medicare, of course, that is a whole presentation in itself. But just for anybody who may be just getting into this side of things and might not know this yet, it is very important to know that you do have options when it comes to your Medicare enrollment. Now, if you want to be reimbursed by Medicare, or at least have the patient be reimbursed one or the other, then you do have to enroll as your organization or your practice, basically, as a Medicare DME supplier. Now, when you enroll, that's when you can choose, do I want to be a participating or a non-participating DME supplier? And the big difference is, of course, participating. Participating means you are accepting Medicare's allowed amount and writing off the rest on every claim. Non-participating DME suppliers do have an option to do what's called accepting assignment or not accepting assignment. Okay, so again, Medicare is a whole topic on its own, and I definitely encourage you to find out more about it if you haven't gone down that route yet. But you can choose to enroll, but you can also choose to opt out. If you say, you know what, doing the Medicare thing is not for me, you can choose to opt out of Medicare. But always be sure that, you know, if you do choose to opt out, be sure it's something you really want to do. Be sure you want to do it because it does last for a two-year period when you opt out of Medicare, and it will auto-renew every two years unless you cancel that opt out. So again, just weigh your options and make the best decision for your practice. Now, when it comes to the commercial and private insurance company in network enrollment, what you'll find is that some commercial or private payers will enroll a dental practice as a DME supplier, or sometimes they'll call it like it'll be in the ancillary provider section, very similar to how Medicare does it. Instead of enrolling as a, you know, a dental practice or a clinic, they're enrolling you as a DME supplier. But not all private or commercial payers handle it that way. As I mentioned at the beginning of the presentation, there are variances from region to region and insure to insure on the way that they handle their enrollment process. Great news is you can typically find out right on their website exactly what they want you to do. But again, as I mentioned, the commercial or private payer in network enrollment process is expected to be lengthy. You do want to follow up consistently. And it's definitely not impossible. However, even when everything goes right, even if that network enrollment was, the application was completed perfectly, you will run into certain obstacles. And a big one that I see is a panel closure. They'll say, thanks for the application, but we're full up right now. Try back later, whether later is three months, six months, you know, it depends. Now, the great news about the panel closure obstacle, of course, it's not foolproof. I don't think much is in medical insurance, but the great news about that panel closure obstacle is the insurance company is saying that their panel is closed for a certain provider type. In their eyes, they're saying, we have plenty of this type of provider. But the great news is I can almost guarantee you not a single one has plenty of in network dental practices who are providing custom oral appliances for OSA. So again, if you are going down the in network enrollment route, and you do run into that response, you know, be sure to respond and say, look, I totally understand that your network probably is really full of providers like us. However, we are unique because of the type of custom DME we are providing. And I can guarantee you that you are not full. And again, not foolproof, but make sure that you stay on top of those because it's easy for an insurance company to just say, you know, we're full right now, try again later. All right, so let's do a quick recap, because I know we, we covered a lot of information that you're going to need to put into different websites and portals. So let's bring it all together. Now, the three tasks that you want to complete, if you haven't already, number one, do your NPI assessment, find out what is currently registered to your type one or your personal individual NPI and make updates to it through the INA, the NPP ES login as necessary. Or if this is your first time getting an NPI and you're just getting started, go ahead and get it applied for. Also, figure out whether you already have a type two NPI or if you need one. Again, that would be practice owners for their dental practice organization. Second, CAQH assessment. Make sure that you have a profile that is absolutely as complete as possible. Again, there are certain parts of that CAQH profile that won't be applicable to you, but just make sure you fill out every page that you can and it will make your life easier in the future. And finally, make sure that your practice has profiles for Availity and NaviNet and that your business and provider information is registered and correct. And again, just always check for updates. Be sure that you are re-attesting, well, for your Availity and NaviNet, typically every 90 days, for your CAQH, every 120 days. And just again, I can't stress the more accurate and up-to-date the information is in your CAQH profile as well as your NPI profile, that is going to make the credentialing process smoother down the line. So to clarify, the CAQH profile, is that for only in-network or out-of-network providers or anyone looking to bill medical? Great question. Anyone looking to bill medical. Great. And then we had a comment that the CAQH website is awful and it is miserable process. Can you elaborate on some of the challenges that might be faced by dentists filling in that information? Absolutely. I understand, the navigation on it is not the worst, but there is a lot of information and a lot of pages. I understand it is not fun to fill out. The good news is I think, they have made some, what I feel like are pretty good improvements where if there's something missing or wrong, they highlight it right for you and you just go straight to the red X and fix it until it's green. So I do understand it is a lot of information to fill out if it's the first time filling out your profile, but you just gotta do it once and then just update it from there. Great. Our next question is a Medicare question. If you participate in Medicare, do you have to accept the Medicare Advantage Plan allowed amount? Great question. So this is an it depends answer. So the Medicare Advantage Plans, if you have not enrolled as a provider for that Medicare Advantage Plan, then yeah, you are not an in-network provider with that Advantage Plan. So really the question is, are you enrolled with the Advantage Plan? Because if so, then yes, in-network provider and you would be expected to accept that allowed amount. However, keep in mind the Medicare Advantage and original Medicare allowed amounts are not always the same. Thank you. Next question. Do we bill E-0486 and 21085? And can you elaborate on those? Great question. So that is a little bit outside of the credentialing topic. So code E-0486 is, you know, definitely a valid HICPIC code, medical billing code. It's a equipment code to represent a custom made oral device that's being used to treat airway collapsibility, right? What was the two code? Was it 21085? Yes, it just disappeared from me. That's okay. So I believe it was 21085. So 21085 by definition, if I can remember it, it's impression and custom preparation oral surgical splint. Is the definition on that code. So it's not one that, you know, I would recommend using to represent a custom made oral appliance for OSA. However, if you are fabricating a surgical splint, any oral surgeons or anything like that, that is an appropriate code for an oral surgical splint. Thank you. I have a taxonomy question. Will you get reimbursed as a general dentist with a general dentist taxonomy code or do you need a specialty taxonomy code? Fantastic question. Yes, you can get reimbursed with the general dentistry taxonomy code. That's actually most of the providers I've worked with over the years have it exactly like that. General dentistry for their primary taxonomy. Awesome. Next question. At what point when negotiating a network credentialing, do you find out what a company reimburses for the EO486 code? Do you have any recommendations for negotiating the fee or is it typically non-negotiable? Oh, that is such a fantastic question. So the negotiating portion of it is something that varies some from insurer to insurer. Some insurance companies you actually can negotiate that prior to like accepting the contract. Some you actually have to negotiate after the fact which is of course never fun. As far as tips, I think when it comes to negotiating an allowed amount for a sleep appliance, the best thing to have ready is what your costs are, right? What your overhead is. So that way if you have an allowed amount that is just so low, you can very easily show that this is how much it costs us to do this. We do have to make a little money here. And so I think though with certain payers that you will run into, once you have accepted that contract, there may be, read those contracts. I know those are not fun to read but there may be a clause in there that says once you have accepted that initial rate that basically you're stuck with it for one to three years, okay? So if it's a rate you can't deal with, do make sure you negotiate it beforehand. Thank you. Our next question is, do you have to opt out of Medicare even if you choose not to accept Medicare and want to only work with private insurance? Oh, great question. So you do not have to opt out of Medicare initially. However, there is again, I don't know how often this is policed or anything but there actually is guidance in Medicare language that says basically the first time that you have a patient enter into a private contract. So a cash pay situation, if you are not going to enroll, you technically have, I believe it's somewhere between 10 and 30 days to make that decision to enroll or opt out. So I would suggest to go ahead and make a decision one way and where the other, at least by the time you see that first patient. Our next question is, can oral facial pain specialists be an actual Medicare provider, i.e. bill for EM codes or just a DME supplier? Well, that's a great question. So that is a very different enrollment process. So for Medicare DME, you're enrolling the organization, basically enrolling the practice, the location into a section of Medicare called Medicare DME, totally different enrollment process. So for an oral facial pain specialist enrolling as a Medicare provider, that is what's known as a Part B, as in boy provider. And so it is a different enrollment process, different enrollment application and all of that. So you could choose to enroll as a Part B provider if you wish. But you wouldn't be billing the same place that you would bill your sleep appliances, basically. Thank you. And then our next question, we already answered that one, but what is a network deficiency? Yes, I'm sorry. I should have expounded on that earlier. Thank you. So a network deficiency, you'll also hear it referred to as a gap exception, sometimes a single case agreement, all kinds of different terms. But what that means is it's a request to a medical insurance company to honor a patient's in-network benefits, even though they're going to an out-of-network provider. And why would an insurance company do that? Well, it's because they'll typically approve it if they don't have a provider that is in-network within a reasonable distance to the patient. Now, reasonable, of course, the insurance company decides that, but it's typically 30, 40 miles. I've seen up to 75, but that was a while ago. So I'm sure the region does make a difference in everything, but a medical insurer will typically approve that if there's not a practice that can provide a custom oral appliance within a reasonable range. It's basically telling the insurance company, look, the patient would love to go to an in-network provider, but you don't have any, so let them come here. Thank you for that clarification. Another question is, I have heard of billing that is able to get significantly more for OAT that includes Medicare. Are you familiar with this method? That includes Medicare. I am not familiar with that. Nope. Okay. When you credential with Medicare, can you explain again, participating versus non-participating? Wanting to know if we are able to charge my normal appliance amount or use their fees. Gotcha. Great question. Okay, so for Medicare, I always like to say when it comes to Medicare, instead of with like the private payer, the commercial payers, instead of there being like in and out of network, there's like this extra step with Medicare. It's either like, they don't know who you are or you enroll and then choose, do I kind of want to be in or out? It's not exactly the same, but it is that extra step. So when you enroll, if you choose to be a participant, you're not going to be able to use if you choose to be a participating DME supplier. That means that you are accepting whatever your region allowed amount is for E0486 for the code that gets used for sleep appliances. And that's every claim that you submit. Now, the upside to it is the reimbursement gets direct deposited into your bank account, okay? So it makes it easy from that standpoint. Now, what a lot of providers I've worked with over the years will do is enroll their location for their DME as a non-participating supplier. And what that means is you get the choice to either accept assignment on the claim, which will mean it works just like if you were participating. If you say, hey, I'm going to accept the allowed amount, I want the reimbursement right into my bank account. But here's the key, is that you also have a different option on the claim of doing what's called not accepting assignment. And what that means is that you can charge the patient up to your usual fee. You don't have to do the write-off as if you were a participating supplier. However, guess where the reimbursement check goes? To the patient, of course, right? So there's a catch-22, but those are the big two main differences in between participating and non-participating for Medicare. Now, keep in mind, everything that I've just said is similar if it comes to Medicare Part B, but it is not the same. So if anybody is sitting there thinking, somebody told me you can't do that with Medicare, that's correct, you can't for Part B, but charging up to your full fee as a non-participating. So the next question is, many private insurance companies only accept providers as in-network if you are an oral surgeon. How do you get around that? I know Aetna is one of those. So how do you navigate? Yeah, and I've seen certain insurance companies say, oh yeah, we can't offer that professional services contract. Yeah, unless you're an oral surgeon. I don't know about Aetna specifically, but many times those payers will have an option to enroll as a DME supplier, similar to Medicare. Again, not exactly the same, but similar to Medicare. So check out their ancillary provider options as well. Of course, if you're enrolled as a DME supplier, the catch there is you're not enrolled for professional services, for office visits, x-rays, TMD, things of that nature, but it would achieve the in-network status for the appliance. Great, and then next question, for a university, how do I get medical credentialing? Oh, fantastic, so usually the universities are gonna have a credentialing department. So if you need the credentialing department to get you credentialed under their information, then I would just get in touch with the credentialing team. They're gonna ask you a lot of questions, ask you to provide a lot of information. And then our next question is, how do you go about opting out of Medicare? Is there a specific site? Great question, so opting out of Medicare, I would encourage you to go to the, what's called the Part B, Part A and B MAC, M-A-C for your region. If you Google your state and say, you know, Medicare, just say Medicare Part B MAC, and then type in your state, you'll find it. And certain, most of the regions actually give you a little templated letter that you can use to opt out, but there's no like specific enrollment form you think there would be. There is for everything else in Medicare, right? But it's, basically they do give you a template letter that you can use, and it is, I believe, still mailed in. Great, thank you. Next question, if we were giving patients a service that has no code, like nasal dilators, do we give it a miscellaneous code? Can we make them pay out of pocket even though we are in network? Great question, so for, yeah, nasal dilators, you could certainly, yeah, use a miscellaneous code to represent them. Typically, unless your network contract states otherwise, that you should be able to have them pay out of pocket because that would be basically considered a statutorily non-covered service. So if it's something statutorily non-covered, you typically can go ahead and charge the cash and it works great. But double check your in-network contract, just make sure there's no language that indicates that you cannot charge the patient for any codes not included on your fee schedule. That's not something I see on every contract, but I've seen it. Another question here about Medicare. What is the difference between not applying to Medicare at all and applying as a non-participating provider? No, great question, because I think I get the question a lot. Well, if I enroll as a non-participating supplier or provider for Medicare, does that mean I don't have to follow their rules? Nope, it doesn't. You do still have to follow all of their rules as far as coverage criteria and billing and documentation. But the big difference between not applying to Medicare and being non-PAR is if you enroll as non-participating, you can get the patient coverage. If you don't enroll, the patient can't get coverage. That's the main thing. Thank you. And then our last question for the evening is as follows. We are out of network on commercial plans, but EOB comes back showing allowable amounts and patient's responsibility is, for example, 20% up to the allowed amount. But because we are not in network, we can balance bill for the differences in our fees to the allowable amount, correct? That is correct. When you are out of network, anything, unless you have signed some type of single case agreement that says, I won't balance bill the patient. If it's just your usual out of network case, no special agreement signed, then yes. Anything that the patient's medical insurance does not cover is patient responsibility, period.

Ari Wolfson

Courtney Snow

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