There is a lot of information, and I know as staff members, you've all been there when the dentist has come back from a CE course, and here we go again. But really, in the world of dental sleep medicine, the staff has to be on board. So someone on the staff has to kind of be the cheerleader to really get the ball rolling. There is a lot to learn, and once you get patients there, and the patients are excited, they want to know, how much does it cost? Do you take my insurance? How much are they going to pay? And how much is really coming out of their pocket? Medicine is totally different. Physicians are very concerned about cost. They make recommendations based on that. So the physicians want to know, how much does it cost? They want to know if you're a Medicare provider, and do you accept insurance? Are you in network? These are all questions that your physicians will want to know. So the hard reality is, how you handle the insurance is going to greatly impact your practice. You have to know your area geographically. My area is very competitive. If you're in Des Moines, Iowa, it may be different. You have to know your area and what's going on as far as your participation, Medicare's participating, not participating, insurance, if you're in network or out. So it's a very crooked road. You're going to hear a lot of information, and so you have to take a little time to sort through it and figure out what's right for you. But every medical insurance company has a medical policy that you have access to, and that will give them guidelines for their policies. You have to, patients have to meet those guidelines if you can get oral devices covered. And they're all online. So the first step in getting insurance to cover is to find out if it's a coverable item, and that's by determining their benefits. Before making any calls to your insurance company, you need to know your patient demographic information, their name, their birthday. You have to know your tax ID number, your NPI number. You have to have a diagnosis code from the physician, and on this initial call, it's just the obstructive sleep apnea, the G47.33. What procedure code do you want to know if the insurance cover is covering? Generally, you definitely want to ask about the E0486 to see if it's covered or if it's an exclusion. You have to have their insurance card. You want to know, is this an active policy? Is it a calendar year policy, or is it on some other date range? What is their deductible? How much of their deductible has been met? And what their copayment for the procedure is. So what a copayment is, is the insurance company will say after the deductible is met, we'll cover 80%. That means the patient's portion is 20. And what is the maximum out-of-pocket? What happens with the maximum out-of-pocket is after that number has been met, then they will cover 100%. And is an authorization required for whatever code, the E0486 primarily, is an authorization required? And if it is required, how do you get it to them? If no authorization is required, I, in our office, we will always submit a predetermination. That's our choice, because to us, we have notified the insurance company that we intend to do this procedure. And they can't come back to us later and say, well, you didn't notify us. Make sure you have the correct claims address. That also is a game that's often played in the insurance world, where the address on the back of the card isn't correct. The card is three years old, and they've issued seven cards since then. And the insurance company may have their own authorization form. Some of them are specific. Some of them you can just do a generic. But we try and keep those in a binder or a file on our computer. When Dominic was talking about the gap exception, and if that's something you're going to be doing, that's asked on this call also, is that allowed? And how to do it. They're very helpful if you're nice to them. You need to document all of the information that you get in that call. At the end of the call, you need to say, can I have a reference number for this call? Who you talked to, the date and time the call happened, and the reference number. All of these calls are recorded. And we have had instances where we were given information, and later the insurance company came back and said, no, that's not it. And we've made them pull the calls. So if you have all the information, you can go back to that. So for the authorization, you have to submit as much information as you can. You're building your case as to why this should be covered. So you're going to want the 1500 form, which is the insurance claim form, filled out with the codes that you're submitting, and any supporting diagnosis codes that you have. You want the sleep study, any progress notes that you have from your physician, the referral or prescription form from the physician ordering the device, a letter of medical necessity as to why it's required. We submit an upper sleepy scale. I'm not a fan as a medical person. I think it's too vague, but they like it. If they've been using a CPAP affidavit, or CPAP, and they're choosing, they couldn't use it, we need an affidavit as to what happened. Again, you're building the story for the insurance company. The more information you give them, the better off. Unfortunately, all authorizations and predeterminations state very clearly on there that it does not guarantee payment. So that's why it's your job to have looked at that medical policy so that you know if your patient qualifies. Medicare does not require an authorization, but you have to know the criteria and documentation to have in place to make sure your patient's qualified. Submitting a claim. You have to complete it on the 1500 form, and the HCFA just means Health Care Finance Administration form. They're online. I guess you can still do paper, but the paper is really asking for a huge delay, because then they scan it in. If your software does not have the ability to complete the forms, you can get a template online also and manually do it online. The ICD-10 codes that are used, obstructive sleep apnea is the 47.33. There are some supporting codes that you can use. I gave you an example of hypertension, and I put in here also diabetes, but you have to know from your physician which diabetic code you're going to be using, because there are several. Those codes come from your physician. Those are not from you. The CPT codes are common codes that are used to describe what you're billing. And the HCPCS code is used for the DME. So E0486 is for the oral appliance. These are the billing codes for exams. I will tell you, we are networked with a couple of insurance providers. For some of my providers, I am allowed to bill these, and for some, I am not. That is something that you can ask. But the thing that's different between an exam dentally and an exam medically is dentistry we bill by procedure. A crown is a crown is a crown. It doesn't matter if it took me 40 minutes to prep it or if it took me 90 minutes, it's still just a crown. In the world of medicine, it's time and difficulty details. So a 99201 is a 10-minute face-to-face, but there are certain criteria that have to happen in that face-to-face, and that has to be documented. But if you are going to be billing, and these are new patient exam codes, so you can see there's differences, the limited history, standard history, and that's a whole documentation lecture that takes a while as well. If you're allowed to bill for some follow-up evaluations, these are those codes. And again, there's criteria and documentation that has to happen to support this. Then again, the two x-rays that we primarily see. And the appliance codes that Dominic talked about. I will tell you, I don't submit anything but the E0486. If you have a private insurance carrier and you want to ask about the appliance repair, you can. We have never submitted for the repair or replacement parts, but it is a code out there. Part of the reason that I bring this up is because just because it's there, just because you can, doesn't mean you should. It doesn't mean you should. So I would do a little further investigation before you would ever use any of these other codes. When we're billing for Medicare, down at the bottom it says modifiers. On a Medicare claim, you always want to use the modifier new and unused. You have to remember for Medicare, you're considered a medical equipment supplier. So for instance, a wheelchair. A wheelchair gets billed. It may not be new because it's been used by someone else. They've cleaned it up and they move it on. So new and unused is what we always do, unless you're refabricating somebody's oral appliances. I don't know. And the other thing that we do with the Medicare is the KX is a Medicare modifier. And when you put that KX on your modifier claim, you're saying, I have all the required Medicare documentation. I'm saying I have it all. If you don't, then don't put it on there. Then they're going to ask for your records. But that Medicare requires the face-to-face before the patient has a sleep study, the sleep study notes, the face-to-face after the sleep study, talking about treatment, and then the prescription. Those are all required documents from Medicare. There's a part on there for a place of service, 11 is your office and 12 is home, the E0486, because where our medical equipment being used at the home is actually where it should be billed for. The big thing with doing this is follow-up. It's a multi-stepped process, and you have to develop a follow-up plan in your office that works for you, because there's so many parts where you have to kind of follow up. When you send in the authorization, just because you sent it in, did they actually get it? How long do you want to wait to find out? We have a two-week system in our office where we cycle through every two weeks to check everything. I don't want to wait 30 days and then find out they never got it. Where in the process is the authorization? It'll go through certain, sometimes it'll be a nurse review, sometimes a physician review, so you kind of want to follow up to see what they're doing. When you send in your claim, did they receive it? Where is the process at with the claim? When the claim was received, was it correct? Were they asking for documentation? Probably I would say 10 years ago, I never got asked to submit anything, and it is very commonplace now for them to call and say, we need this sleep study, because maybe they had a different insurance carrier when the sleep study was done. People change insurances very frequently, so the insurance companies don't know. Even though you sent it with the authorization, they still don't seem to know. If the claim wasn't correct, you can correct the claim and resubmit a corrected claim and follow up again, because sometimes when you type in buttons and things get translated through your electronics, somehow things seem to change, so I would always follow up. The other thing you have to follow up is your patient's payment. What policy does your office have? How are you tracking that? You have to put where you fit in in this whole puzzle of insurance, and the whole team has to understand the process. Everyone in the office ends up being involved in dental sleep medicine, whether they are excited about it or not. Somehow they all are involved. Being in dental sleep medicine gives you an incredible opportunity to change people's lives. I encourage you to do it for the right reasons. There can be some financial gain, but the people that come into our office are desperate, they're tired, they've not been listened to, they've not been treated well, and sometimes you're the one people that will take the time to hear their story and do what you can to help them. In our office, you actually have a consultation with me, and after spending 30 minutes with talking to me, I have a lot of patients that will go back and go on their CPAP, because that's actually the treatment they should be on, but nobody's ever taken the time to explain to them why, why they need to be on it, what it matters, so I guess that's my parting kind of thought is, this is an incredible opportunity you have, I hope you will take the time to kind of embrace it, to do it well, and to do the best you can and treat the people, treat the people, so I think that's great. I do have some suggestions, if that's what you guys would like, on things that you can do in your office to kind of follow through, they weren't sure I would have time for that. We have a checklist in our office, so even though we are paperless in our office, I have a little plastic sleeve, and every one of my sleep patients has a plastic sleeve, and in front is a checklist, and it will go through, do I have their driver's license, do I have their insurance card, do I have their sleep study, I mean, there's a checklist, so anyone who picks that folder, that sleeve up, can see what's missing. We have on there when follow-ups happen to different insurance companies so that it can continually to be cycled, I know some people like to put it on their calendars on the computer, that's a great way to follow stuff, we are much more of a hands-on office, when we tried the calendar, things didn't get done, so we have an accordion folder with dates, and those plastic sleeves go in that accordion folder, according to when something has to happen, or we should have something back that we don't know about, so those are some suggestions for you, and the other thing that comes up is, how many of you are still practicing dentistry also, so what happens when you have a dental patient that becomes a sleep patient, do you want to merge all that information together, do you want it separate, those are some decisions to make, we separate ours, just because it makes it a lot easier when I'm looking for stuff, if I can look at that, we use a different provider on our clipboard for our sleep patients, then we do our dental patients, our dental patient is, for instance, me, it would be Belinda Postal, and if I were a sleep patient, it's Belinda Postal 1, we put a 1 behind all of our sleep patients, so that we can find that, it's easy, it's simple, it doesn't require much more, some other things we do, follow-up, when we see patients for a consultation, that goes back into that cycle, if we haven't heard from them to set up an appointment, if I sent them back to see a physician, that's my responsibility, did you go back, have you talked to them, I send the letter to the physician saying they're going back, but I like to kind of prod those patients along, because I'm treating people, we're treating people, I'd be happy to take any questions, as I said, this was a pretty basic entry level, what I see really being the biggest roadblock for you all is documentation, because medical documentation is different than what you're doing in dentistry, so I would take a little bit of time to kind of learn what I should be documenting to support these codes.

staff involvement

dental sleep medicine

insurance coverage

authorization

follow-up plan