Welcome, everyone. I am Dr. Claire McGorry, a member of AADSM's Education Committee and moderator for this evening's presentation on Practice Models of Dental Sleep Medicine with our panelists, Drs. Arthur Feigenbaum, Greg Osborne, Jonathan Parker, Kevin Postol, and Ms. Belinda Postol. And now I'd like to invite each of this evening's panelists to give a brief one-minute introduction that includes their type of practice, the length of time they've been treating patients with sleep disorders, the evolution of their practice, and what percentage of their practice is dental sleep medicine. Let's begin with Dr. Kevin Postol. Dr. Postol. Good evening, everybody. I've been treating dental sleep medicine now for going on 15 years. I have a combination of a general dental practice and dental sleep practice. Before COVID, I would have told you my dental sleep practice was 80%, and I had 20% doing sleep medicine. I am now a general dental practice that's at about 60% and about 40% dental sleep. I am in St. Louis, Missouri, and I enjoy very much doing both disciplines at this time. Belinda Postol. So I'm a registered nurse is my background. And so I work with Kevin, and I have the luxury of being able to handle things before the patient actually sits in his chair, which includes a lot of education for them medically, which sometimes means they don't get an oral appliance. So that's kind of a unique feature that we offer. Great, Dr. Jonathan Parker. Good evening, everybody. It's a pleasure to be here. I've been in dental sleep medicine practice for 29 years and dentistry for 38 years. And I've been doing dental sleep medicine full-time for 20 years. I have a private practice in dental sleep medicine, and also I'm gonna talk more tonight about being involved with a health system-based clinic or hospital-based sleep centers as well. And I have to say that when I started, I pretty much had to develop my own systems and convince colleagues in medicine and dentistry that this was something that was real and was important. And things have really changed. And so my thoughts and opinions have changed over the years. I think just through evolution of what's been happening, and I'm really excited for all of you, and I'm glad you're here to hear this. And my claim to fame is that I was a classmate of Trish Braga's, so... And I have to say, I'm thrilled to say that. She is an amazing person and is doing a great job with the Academy. So that's my plug for Trish tonight. So thank you. Dr. Gregory Osborne. I'm in San Antonio, started Sleep Easy Dentistry, which is 100% dental sleep medicine practice about four years ago. But my journey began as a general dentist way back in 1981, when I started developing a small group practice that I sold after 35 years to my younger associate. I continued to work with him part-time for this practice. But back in the mid 80s, when I was doing orthodontic treatment, I did start working with mandibular advancement devices and palatal expanders, and realized that possibly I was helping some airways when it was kind of an unproven area. I was hoping it would work, but my oldest daughter was having all kinds of issues and it helped her. A lot of family stuff. My cousin had married a pioneer sleep specialist way back when, Dr. Martin Wright. He's a contemporary of Dr. Bill DeNette, who founded the American Association of Sleep Medicine. So my discussions back in the 80s and 90s with Dr. Wright, led to a lot of interesting connections. He said, well, some of those snoring appliances that you dentists make might help patients like my dad, who had sleep apnea. And I went, you're kidding. You think that that could actually help? So anyway, he published a book. I read his sleep disorder book back in the early 90s. And it just gave me a lot of information about sleep that very few of my friends, neighbors, and dentists, and even physicians really knew back then. It personally helped me to sleep with my wife because she quit snoring after I made an appliance. So I continued dabbling in sleep dentistry for many years, but decided to finally get serious and got my diplomate with the American Board of Dental Sleep Medicine. And anyway, here we are today. All right. And then finally, Dr. Arthur Vangepan. Hi, everybody. I started in dental sleep medicine about 10 years ago. I started working with a physician. He was my physician. He also was a sleep specialist. So we started working together hand in hand, and I've been doing that for the last 10 years. And I also had a general dental practice in the New York area, which I transformed more and more into sleep, did a lot of lecturing over the years. And eventually I was recruited by a large DSO in the New York area to be the director of dental sleep medicine. So that's a lot about what I'm gonna be talking about. All right, thank you. I'm now going to ask a few questions that I would like each of you to answer briefly. The first question is, what would you consider to be the most advantageous aspect of your practice model? And I'll start with Hostos. It's very simply in our practice, since I still do general dentistry and sleep medicine, I've got built in patients in my office. And I think that's especially advantageous when you're first starting out in dental sleep medicine is that you have patients in your own office that you're gonna screen every day. You're gonna start out by learning how to screen patients, how to start looking at different things, and hopefully there develop a relationship with some physicians in the area of how to refer patients from your own office and your family members. So that's one huge advantage of when you start out with dental sleep medicine of having a general dental practice also. The other thing for us, especially too, is as we're looking closer at what the end of our practice looks like, is there's a lot of security for us knowing that we could sell off the dental portion of our practice and continue on. Right, Dr. Jonathan Brekker. So the health system based practice, essentially I go into the sleep center for the health system, health system being something like Kaiser Permanente or UnitedHealthcare has specific health systems. The health systems are generally run by the insurance companies. So I was contacted by the director of the sleep center at two different health systems, two different hospital-based sleep centers to come in and see patients in the sleep center. And so this is a collaborative model that really strengthens working relationships. It also provides a patient flow. Now I will tell you that isn't always the case, but it really, in one of the groups I work with, our schedule is booked out, we're there one day a month and we're booked out for two months. So it can provide an increased patient flow. And as opposed to my general dental practice, where even though, I mean, my dental sleep medicine practice where I've been working with these sleep physicians for 29 years, and now they're giving the patients a list of six people that they can see to get their care. So again, I'm grateful to be on the list of the six people, but when I'm in the hospital-based or health system-based clinic, they are steering the patients pretty much directly to see me. And I think that's a big advantage. Right, Dr. Osborne? Well, separating my DSM practice a few years ago, but still physically being in the same general dentistry office has helped again, too, like the Postles has said. My DSM staff, though, only work with DSM. We have our own phone number, the website, marketing. The dental staff on the other side with general dentistry, I'm a part of, but as an employee, and they have their own, it's a separate part. The separate business has helped us to attain the ability to build medical insurance and achieve a in-network status. And we became a Medicare Tricare provider, and this all helps make sleep apnea treatment more affordable and facilitating more referrals by doing that. At the same time, we work hand-in-hand with the general practice with a minimal footprint within the office. You're looking at my minimal footprint, basically, and utilize chair time, which would probably be downtime anyway. And this allows ongoing sources of referrals for us from the outside. And we still have our general dentistry, and just doing the hygiene exams gives me plenty of folks to recognize signs and symptoms, to plant a seed. And then I encourage them to do a free consult with Mr. Ruben Avalos. He's this brilliant young man who's a nurse. He's presently the assistant director of nursing for 120-bed tracheotomy ventilator facility, and now he's the director of our operations. Ruben's also become a dental assistant, and he's completed his certification in polysomnography. So I've got a jewel there. He has the most insightful consults. Now the relationships of DSM with the general dental practice is mutually beneficial. We send a lot of patients that come in from us, from the physicians and outside, they need a dentist. And so that has become really a good synergistic force for us, and we share the cost of exceptional technology. We've got a CVCT and a digital scanner for both practices. So that's how it's been an advantage for us. Great. And Dr. Vagabond? For me, the best resource of referrals has been from MDs. When I started with a sleep physician, obviously the amount of patients I got were fantastic. It was streamlined process, so it worked out very well for me. When I joined the DSO, the reason I joined it is because access to so many patients and so many MDs. It's not only a DSO, but we have clinical affiliations with medical groups that have about 3 million plus patients. So just the ability to get in contact with all these MDs and work out relationships has been very enjoyable and a good option for me. Great. Thank you. My second question is, are there distinct disadvantages to your practice model? And I'll start again with Belinda and Dr. Postol. So one of the main disadvantages of my practice model, because I've been doing dental sleep medicine for 15 years now, and in the St. Louis area, I am very well known with a lot of general dentists in my area for doing dental sleep medicine. But as much as because I am in network with a lot of insurance companies, and I try to talk to them about sending patients over to me to treat them, especially if insurance is important for the patient, I still think they don't tend to want to send them over because of fear of me wanting to take their patients because I have the general dental practice. Or if I only did sleep medicine, I don't think that would be as big of an issue. So I don't think, at least in the St. Louis area, I'm going to get a lot of patients from other dentists because of the fact that I still do general dentistry. From my perspective, the big disadvantage, especially when we were starting off, is having staff that was willing to do both dentistry and sleep. And then clearly the medical billing perspective is a disadvantage. We have it well handled, but if you're starting off, that can certainly be a challenge. Right, Dr. Parker? In a health system-based practice, the physicians were working side-by-side with the physicians. And I don't know whether you, it depends on your viewpoint, but some people would say that if you're going to do that, you probably are going to need to be in network with most of the medical insurance carriers. And they would like you to be in network with Medicare, the sleep physicians would. So some people would view that as a disadvantage because reimbursement is not going to be as good as if you were in a fee-for-service practice. Others would say you're improving access to care to everyone, and that's a big advantage. So I think it depends on how you look at it. But I think working with insurance carriers is something that in this particular practice model with health systems or hospital-based practices would be necessary. Great, thank you. Dr. Osborne? Well, the challenge, I guess, to duplicate our model is finding someone like Reuben, that nurse that's so passionate and knowledgeable about sleep dentistry. We also hired a former paramedic as our first employee with her medical background. And then part of my education came kind of the hard way with raising a third daughter who had special needs. She had Moebius syndrome, which is facial cranial nerve damage that occurred before birth. So for 28 years, we've been caring for her needs with pulse oximeters, a ventilator most nights, and managing the most successful treatment for sleep apnea, and that's a tracheostomy, which she needs to survive. She can't swallow without aspirating. And that's how I met Reuben. It's been really providential in some ways because he was helping with my daughter. And so I told him, I'm dabbling in sleep dentistry. I tried to develop a sleep ambassador for my team. And you may find you end up pulling away one of your top dental assistants, or even more problematic is pulling away a dental hygienist because they are a significant producer for the general practice. So hiring a nurse and getting them up to speed on DSM has worked better for us, is all I can say. Since we've duplicated our model in other offices, we're doing it in different ones, we've had to equip them too. Now this doesn't take much equipment for sleep apnea, but we take a lot of it with us, but that's something that you gotta be kind of used to. I used to take students into other countries and do dentistry, and I developed the geriatric offices here in town where we could go there. So I'm used to going other places, but you have to kind of ask yourself, is that something you'd be comfortable going to different offices in what I'm doing? But if I can do it, you guys and gals can do it too. So that's my encouragement to you. Thank you, Dr. Feigenbaum. Yeah, so for my DSO, I think there are a couple of problems. One is it's a corporate structure. So there's a lot of red tape. When I make a decision that I want implemented, it could take quite a while to get it implemented. So that is one of the problems I have. The other one would be there's 13 offices and they're growing to about 20 in another year. And just so many personnel that we have to train and make sure they're doing the right thing. So that can be complicated as well. As far as the sleep physician I work with, the problem we have there, at least in my eyes, is the fact that he also practiced internal medicine. Because of that, we don't get referrals from other primary care doctors as much as we should. So that would be the downside of that arrangement, although a small one. All right, thank you. My third question is what impacted your decision to establish this practice model? And back to Belinda and Dr. Koster. So when I first started doing dental sleep medicine, I sat at a course and the course had nothing to do with dental sleep medicine at the time, 15 years ago. In fact, I didn't even know what sleep apnea was. And we sat at this course and Belinda was sitting next to me and it was a practice management course. And the gentleman that was at the course was talking about how we dentists could treat patients who had sleep apnea with oral appliances. 15 years ago in dentistry, as I said, this was not something that was very well talked about. And he went through some of the symptoms and she sat next to me and said, I had every one of those symptoms. So I then started looking into different courses. That's where I met John Parker and took his course and it very slowly became a part of my practice. I have learned that dental sleep medicine is not like adding implants or Invisalign or doing more endo in your practice. It's a totally different aspect of adding a new service into your practice. It takes time to develop. It's not gonna be something overnight, but I would say the biggest thing I've gotten out of it is what I can do for people more so in this and helping them with their lives is way more fulfilling than anything I've ever done in general dentistry. I don't really have anything to add to that. All right, great. Thank you guys. Dr. Jonathan Parker. So I had a dental sleep medicine practice here in Minneapolis for a long time. And I think the decision to expand it into a health system based or hospital based model or add that to our dental sleep medicine private practice was that I wanted to, I had relationships with a lot of the sleep physicians in town, but I wanted to strengthen them. And this has been a great way of strengthening those relationships. And it has been, I think, synergistic with my dental sleep medicine private practice. And we've been able to really sort of move into the hospital-based clinic, the sleep center, and manage patients pretty well. I think the big challenge that I ran into was how are we going to see them from start to finish with care, and right now, we're having to use our private practice to do the treatment and the sleep center for the initial consultations. And I'm looking at expanding in the sleep clinic to do start to finish care, because I'm hoping that that will be another effective way of managing patients and having the patients come to the same place each time for their care. So it was really to help strengthen and grow the practice outside of just the private practice. Thanks. Dr. Osborne? Well, after selling my general practice, I really did try to utilize the dental staff to help, you know, increase my efficiency of treating these sleep patients. But dental and medical insurance are so different. I found it, you know, very difficult, as Belinda said, about, you know, having someone do both. My goals when I decided to form 100% DSM were to, you know, to prioritize access to care, to communicate better with the medical professionals, and to educate others. With a medical nurse as a daughter and home nurses in my life, it just finally kind of connected. You know, I just went, hey, you know, that's the missing link between us dentists and these physicians that I'm having trouble with. And, you know, I think it goes back to medical and dental school. It's, you know, really an inordinate division that we kind of set up 100 years ago. The nurses can communicate with the same language as physicians, yet they can be trained by dental personnel to understand the vocabulary and our peculiar methodology that we have. So after selling my practice, I no longer had any staff except for a retired office manager. I pulled out of retirement for bookkeeping. And then my sons, son-in-laws, and my daughters, they were very supportive and helped me get the systems and kind of temporarily manned the phones and set up for software. And that's how I got it started. It wasn't easy. Great. Thanks, Dr. Beigenbaum. Yeah. So, you know, since I've been doing dental sleep medicine, I've realized that, and I'm sure we all realize that we're making a difference, a big difference. And the fact, for me, the type of practice I want to be in is where I could see as many people as possible to make a difference. And I had opportunities, which very few people will have. I mean, I consider myself very lucky to have two of the best positions in the New York area for somebody involved in dental sleep medicine. So I feel really good about it. And there's no way I could have said no to these opportunities. And I'm having a great time doing it. Great. Thank you. Our next question is, what significant challenges did you face when establishing your practice model? And are there challenges to maintaining it? Postress, back with you. We actually had a sleep meeting at our staff today, because as you grow, there's continual changes and challenges, so. I think the number one challenge anybody's going to have if they're doing general dentistry at this point and try to add sleep into their model, it's called STAFF. It's going to be the biggest challenge. And I will tell you that my first couple years, it was a very large challenge. And it wasn't until at that point that I got Belinda to start working at my office where she took it under her wing. And I don't think it would have ever happened if it wasn't. It takes a little luck at some point, and you've got to have the right staff members on board. The two staff members who I had doing it before Belinda came on got overwhelmed with it, because it's developing those relationships with the physicians back then. It's developing new systems. It's developing a whole new way of thinking in the office. We had to learn that my dental sleep practice and my general dental practice are two totally different entities. I understand why a lot of people end up not doing dental sleep medicine. You've got to decide how big do you want it to be. Do you just want to treat the two or three patients you see a month? Or do you want to have it where it becomes a large portion of your practice where you're treating 25, 30, or even more patients a month like we do? That's something that each person has to decide. And I know there's lots of people who are, you know, diplomats of the academy who only treat two or three patients because they're not in network. You've got to decide in network or out of network. What is the advantage? How best does it fit your system and your practice and your lifestyle and how you want to do things? In addition to the staff, the issue with incorporating into a dental office is the schedule. There's also the component of figuring out how that schedule is going to work. Are you designating a specific time just to do sleep? Are you working that into your general day? And as you evolve and grow, that also changes. So it's a constant evolving process. Thanks. Dr. Parker? So in a, well, it's different for a health system or hospital-based practice model than it is for a full-time dental sleep medicine model. Related to the hospital-based model, I think one of the biggest challenges that I've run into is that in order to create this model, you have to have, you know, you have to start a conversation with the director of the sleep clinic. And unless they're a friend of yours or you have a long history with them and, you know, it's challenging to find the time where both of you can meet and talk about this opportunity or potential opportunity, and you need to find partners that you can collaborate well with, really people who have a similar philosophy. And so interestingly, I was contacted by a clinic that wanted us to come in. And after meeting a couple times, it became clear to me, and I know these sleep docs, it became clear to me that our practice philosophy and how we wanted to work within their clinic, and our practice is totally focused on patient experience and also keeping our staff and the team healthy. And I didn't have the sense that that was a shared value. And so that is another piece that you have to decide. And it wasn't worth it for me from a financial standpoint. That didn't overshadow the fact that these were the two values that we have in our culture that were more important than the financial benefit we could have gained. So that's another piece that I think is really important to look at is, first of all, you know, the challenge of trying to actually have a conversation with the director of the sleep clinic and that they'll actually sit down with you. And number two is making sure that you're philosophically aligned. Thanks, Dr. Becker. Dr. Osborne? Very, very important there. Well, you know, with trying to do 100% sleep practice within the same office that I used to own, you know, I was trying to find just a small area, keep the, you know, keep the overhead down and find a small area to develop and not step on the toes of the dentist and the staff that, you know, that we're sharing space with. We wanted to be an asset to their general practice and not a distraction. We actually took an old closet-sized storage room, which I'm in right now. It was kind of the electrical hub, and we transformed it into our little consultation business office. It took a great bit of faith from our, the new owner dentist, you know, my new boss to allow us to do this, but we worked it out. The dental referrals, again, that we quickly started, you know, referring to them kind of paved the way to make this a little bit easier for them to understand that this could be mutually beneficial. We even started in another general dentist office in a different part of town. I tried expanding into an oral surgeon friend's office and even an EMT's office so we did find it was kind of easy to refer a lot of stuff to the EMT's, the oral surgeons, you know, that I was working with. You know, there's tongue releases and torii removals and orthognathic surgery, but really that's not a lot of my referrals. It's some, but not much, so then the pandemic came along last year, and, you know, I'm back to having to do a little bit more general dentistry than I really wanted to do, but I guess my advice is don't quit your day job when you start DSM. Kind of hang in there. There's some ups and downs that come along with it, but it's all for the right reason. All right. Thank you. Dr. Feigenbaum? So this webinar is about practice models for DSM. In reality, I had to develop 14 different models because of 14 different offices. So for instance, one office upstairs is a sleep physician, so the referrals are very easy going back and forth. Another location may be very distant from a sleep physician where we may utilize telemedicine, and other locations I had to find sleep physicians that would be clinical affiliates of ours that will do our interps and work out relationships with them. So basically, as I say, I could go on and on about that, but I had to develop 14 different models. It was challenging, but also, again, I enjoyed it like nothing else. All right. Thank you. So our next question is, do you have advice for listeners on critical steps or preplanning that should be undertaken to transition towards your practice model? Starting back with Dr. Postongo and then. You've got to develop systems. You've got to take the right courses, and I think our mastery allows a lot of that in developing systems of how to start treating patients. But as important as learning how to treat patients, you've also got to develop systems of how you're going to go through helping the patients pay for the appliance. In the beginning, I don't think it's important because the FedSys, I think you should do a lot of appliances, basically, either for costs or just for the experience itself. So you can learn and develop the models with your staff. Later on, I think the flow of if you're going to be in network or out of network with patients is important to develop, and it takes a lot of time and effort. And I'll be the first one to tell you, if it wasn't for Belinda, I wouldn't be where I am today with dental sleep medicine. I think that you have to have some idea of where you're headed, because if you don't know where you're going, it's hard to put together the roadmap to get there. And that roadmap can change. Your destination can change, but you have to have some kind of plan with your whole team to get it together. Great, thanks. Dr. Parker? So I think there are really four key elements in making a decision if you're considering going into a health system-based or hospital-based clinic. And so I think you need to ask yourself, number one, do you really like the team at the sleep center that you are going to be collaborating with? And do you share the same philosophy, which is what I had mentioned earlier? And also, is your method of patient management and staff involvement and how business decisions are going to be made, is that consistent with theirs? So those are questions that I think are important to assess with them. Number two is, who has control over the decisions in this model? Are you going to be an employee of the sleep clinic, or are you going to have a practice that's independent within the sleep clinic? So that will determine who has control over decisions, and then you have to base it on what your comfort level is. A third consideration is, does the physical space that you're going to be working in, because remember, these are going to be treatment rooms that are based for medical evaluation. And we've got medical evaluation tables, and if they go up and down or we can move them, the back leans back and so on, that's much more helpful than if it's a table that doesn't have a lot of movement in it if you're planning to do your exam. So the physical space is also an important element. And the last, the fourth, is that you want the people at the clinic that you are going to be collaborating with to be excited that you're there, because it can be challenging if the front desk at the hospital-based clinic is annoyed by the questions, number one, because they don't know the answers, and that's a whole other issue, educating them. Also, whether they feel good about scheduling and doing the things they need to do to help you, because they get accustomed to doing things in a certain way, and now there's a change that comes when you get there. So these are the sorts of questions and details that you need to go through with the sleep clinic administrators, not just the director, but all the staff and so on, so that everybody is on board and working in a collaborative way. It can be an awesome experience. I love being in my private dental sleep medicine practice, but I also really enjoy the variety of going to the hospital-based clinic and working directly side-by-side with the physicians and nurse practitioners and PAs, and so on. It's been really fun, and we have a really good time, and the staff seems to enjoy the days that we come in. Great. Thanks, Dr. Osborne. For us, finding that third-party medical billing group was so important. They need to understand sleep dentistry and TMD treatment. They need to be efficient and persistent at verifying and processing the claims. They need to teach and train, but also listen to the direction you want your practice to go, not necessarily the way they want you to go. Be prepared for a significant investment of time and money with this model that I'm doing. It will feel like you're starting all over again with your dental practice. For me, it did. And you just can't expect to receive a return on your investment very quickly. It's nice to have kind of a mix of private pay patients to keep the cash flow going. A line of credit may be nice to have at the bank to get you through that first couple of years. Many of our attempts really never panned out with our expected medical insurance reimbursement at first. Most of these patients, we didn't even balance bill them, because we kind of promised we'd do everything we could. And so, just like Dr. Postel said, you're kind of doing, well, I said I'm doing some ministry work here. I'm actually helping people. But it's not something I was getting paid a lot right at first. But each time we learned and we learned from our mistakes. And so, just be prepared to spend quite a bit of time, you and someone else on your team, for getting credentialed and getting in network, if that's the direction you want to go. That takes time and a lot of effort. But it's difficult, but not impossible. You may even want to incorporate, you know, the 100% business there and find a good lawyer to help you secure your intellectual property, because it will have something that might have value at some point. Great, thanks. Dr. Feigenbaum? Yeah, I agree with what most everybody said. For me to get to where I am, it's experience, it's education. I think I've tried almost everything, you know, in the years that I've been doing this. As far as billing goes, in-house billing, outsourcing billing, the different models. Listen, not everything worked. I mean, I worked in multi-specialty dental practices, where people were not on board with it. They're hygienists in screen. They weren't interested. They just wanted to do their thing. So, you have to learn what's going to work and what's not going to work. And at the end of the day, when you're ready, you can develop your own model from all your experience that works the very best. Great, thank you. Our next question is, how do you manage and maintain physician referrals, relationships, and communication? And I'll start back with Kostas. We start with letters. It's letters and letters and letters. We in general dentistry don't write letters to our referring doctors very often. We don't really have much communication with them, except for the occasional phone call, occasional lunch, the occasional when you give the patient the referral sheet because they need to have a tooth taken out or a root canal done. In dental sleep medicine, it's totally different. You learn physicians correspond with one another constantly through letters that you either fax or you email to them. However you best find it is the communication they want. When it comes to the other communications, it's all about how much time you want to spend on the phone with them, calling them about a case you might have. Especially the beginning of my practice, I did spend time in sleep labs and I went and visited with many offices and got to know the physicians well. Today Belinda goes out four times a year to the offices to see what they're doing and what they need. I still communicate with them on a regular basis as much as I can. It's hard when you get busy to communicate with them as much as you should, but we try to keep in their good graces at all times because like John said, you know we're on a list of other dental sleep providers in our area. I think there's some of them just have me and one other person. Some might have me, some might have five or six people, and it's amazing how fast they can forget about you. So you got to constantly be in communication with them. And just as important as the physicians, especially in today's environment, it's the physician assistants, it's the nurse practitioners, it's their staff. So Dr. Postol will do a good job in keeping in touch with them. I'm the person and I go out and I'm talking to the staff. What can we do to make the process easier for you when I need things from you? What can I do to make it easier is always what I ask them because you don't want to be a burden because you're always asking them for information. And so it's a matter of being appreciative, trying to make the process as streamlined as possible, and being present. And actually I go out every other month to all the offices, so I am constantly in touch with them and kind of in front of them when we've given them tools to make things easier for them. Good, great. Dr. Brucker? So in the hospital-based model, things flow pretty smoothly because I'm there periodically every month. And so I can communicate with them directly, number one. Number two, I make sure that I send them my notes so that they've got all the information or bring them when I come and they scan it into their system. I also just wanted to make a comment about sort of where things are going. I totally, I enjoyed listening to what the postals were saying because that is everything they said is so vital. I will also mention that over the last many years, we've had, well, for the last 18 years, we've had a fair number of home sleep testing units in our office that we would use mainly for follow-up on patients with their oral appliances. And we have pretty much reduced the use dramatically. We just aren't using them as much anymore because now I am pretty much sending everybody back to the sleep specialist with a fax and my office notes and telling the patient that they need to go back in for a consultation and determine if sleep testing is needed. And that is a huge, huge relationship builder because I will tell you that when you talk to sleep physicians, one of their biggest frustrations is that the dental sleep medicine office is a black hole. They refer the patient out and they never see them back. That's their perception. Now, whether that's reality or not, I didn't believe it was reality in our situation, but that was their perception. So we've pretty much shifted away from doing much follow-up testing unless it's oximetry in some cases to allow the sleep physician to manage the patient more effectively. And that's been a big relationship builder. So I just wanted to throw that in. Great. Thanks, Dr. Osborne. Oh, and I agree, Dr. Parker. That's certainly something we really work hard in making sure that those patients get back for efficacy studies and follow-ups with the sleep. That's so important that they're not lost in a black hole either direction. My practice, for 20 years, I was next to a hospital. So I did get to meet a lot of physicians here in San Antonio over time. And then with a daughter that had a kind of an entourage of pulmonologists and neurologists I met a lot of them. I've worked with CMDA on their council for many years, and that's physicians and dentists that meet on a regular basis. So those kinds of things have really helped and can help others too. I think, you know, anything that overlaps where you're meeting physicians is very helpful. I've worked with students at the dental school and, you know, touched their lives and they've transformed my life for sure. So sleep-easy dentistry starts off usually with, you know, an office by having a lunch and learn. We provide brochures and referral forms. You know, we thank, you know, we thank them with treats. We'll send stuff over periodically. We did today. We sent some over to one of our oral surgeons actually that helps us with some of our cases. And we celebrate good outcomes. Lots of phone calls and yes, Dr. Postel, letters, you know, just over and over. I've never had written so many letters in my life, but it's great. I really enjoy what I'm doing. We had an open house at the general dentist that we started off sharing space with, and we had a dentist, you know, there were dentist medical personnel and patients that showed up. We had a sleep specialist and the ENT, an oral surgeon, and they joined Reuben and me in speaking about our roles in diagnosing and treating sleep apnea. You know, you need to have your elevator speech ready to go at any time too. Every physician's different. Some of them want us to communicate by going over physically and being over at their office periodically and making phone calls. Others just want a letter. You know, we did a two-day symposium in Houston last year, and we've done this a little bit, but we invited an ENT and their two PAs to come, and it's for physicians and dentists. And this is a, you know, DSM course, and what a great way to study together. That was, you know, hugely valuable to us. So I find that with some of the physicians we actually refer enough that we're on the receiving end now. You know, the relationship has kind of shifted. They like the referrals, and we love the relationship. Great. Thank you, Dr. Feigenbaum. Yeah, as I said earlier, one of the jobs that I've been doing quite a bit of is working out relationships with physicians, you know, whatever it is, and understanding their needs. I mean, I have sleep physicians that work that are associated with sleep clinics. They like doing PSGs. We make sure they get back for that. Other sleep physicians do a lot of HSTs. We get them back for that. We have to have this constant source bidirectional referrals all the time. That's the way to build a practice. And all my sleep physicians, everybody I deal with knows me. You know, I've been to their offices. We've hung out, spent time. As I say, I address what they're looking for, what their needs are. They understand what I'm doing, my limitations. You know, it's just to understand each other very well, and once you have a good relationship, that relationship keeps on going, and that's the way I work it. Great. Thank you. Our next question is, do you use special software to manage your clinical records, office records, insurance, admissions, and communication? I'm going to let Belinda answer this one. Being a general dental office doing sleep medicine, we use our dental software to track the appointments, the ledgers, but we do use a medical software for all of our notes and letters and things to keep it all kind of compact. Medical software is much more set up to do the soap notes that the insurance companies want and that the physicians are used to seeing. That's how the physicians communicate, so if you want to be on their playing field, you have to kind of act in the same manner that they do, and so we use a medical software to help us do all that. All right, Dr. Brekker. In our practice, so for the last 13 years, we've had a Mac, well, we have Mac-based systems, so we have a medical software that allows us to basically customize everything that we have in the office, and because it's a Mac collaborative system, we have access to I don't know how many thousands of physicians' templates that we can choose from and pick and choose to create our own forms and so on, so that's what we've done. Great, thank you. Dr. Osborne, you're muted. Thank you. I did switch over to a DSM software, and it's been extremely helpful. You know, I was kind of an early adopter of one of the Windows-based dental programs years ago, and it's improved a lot, but I just couldn't make it fit completely with it. So the one I'm using now, it's a cloud-based software, so it's accessible from anywhere that I have Wi-Fi. I can be at any office that I'm, you know, working out of any treatment room that's got an internet access computer. I can work from my home. My staff could work at home, and that's been, you know, very helpful with telemedicine this last year to have that information right at our fingertips. Online patient questionnaires are there. They can fill them out ahead of time. You know, you get your medical history and all that ahead of time, which is nice. It has an appointment scheduler, which is not as good as probably the dental ones, but we're using it because, again, I'm keeping my practice separate from the dentistry now. It has an insurance claim capability. It has been very organized in counter notes, those soap notes that really come out well, I think, so it helps to, you know, I can communicate with the sleep physicians and the general dentist. I try to know whoever their general dentist is. I'll send them a letter and their PCP, whoever. This company also offers conventionaling help, lab webinars, training videos, and even discussion forums. So anyway, they've been good. Great. Thank you, Dr. Feigenbaum. Yeah, so I've used a combination of things. You know, I've had a sleep software where I've accessed, either it's been on a server where I use VPN to access it, or sometimes I just have it on my computer. I've done it all sorts of ways. I've also used EMRs where, in conjunction with the sleep software, so I will create notes from the sleep software and copy and paste them into the EMR. I've done things like that. Again, I've done everything, you know, things different ways over the years and try to simplify as best as I can. Right now, I'm still outsourcing my billing. I've done it in-house in the past. It's just easier for me, but I think eventually, at least with the DSO, we will do it in-house. It's just that it's a new program and I'd rather have some people that have more expertise in doing it than some newbie because it's such a crucial part of our practices. Great. Thank you. And our last question we have is, do you have advice for listeners on how they should determine which model best suits their own individual needs or situation? I think the first thing that you have to do is you have to know your area because part of your decision could be based on your geographic area. If you have a lot of dentists already doing dental sleep medicine, are they in network? Are they out of network? Are they doing Medicare? If you do an evaluation, that will give you some answers. And then like Dr. Parker said earlier, you also have to know what your goals are, what your values are, and how you want to operate. So even in our practice, our dental practice is fee-for-service, but our sleep practice is insurance-based. So your model doesn't necessarily have to be the same in our situation. So you kind of have to figure out what you need, what works, how are you able to treat the most people that you can. It really comes down if, you know, I heard it from many other speakers in the past when it comes to how many patients you want to treat, especially if you're in a large metropolitan area that there is a lot of people doing dental sleep medicine now that are in network. If you're not going to be in network, you're not going to probably get a lot of referrals from sleep physicians if you're beginning. Not a lot of us are like John Parker, who's had that relationship for 30 years before people started getting in network. Things are a little bit different nowadays as they were, you know, 15, 20 years ago. The market's changed. More people are being treated for dental sleep issues all the time with oral appliances. I find there are patients who will pay about anything for help, but there are a lot who want to use their insurance. And it really comes down to how many patients you want to treat and how big do you want it to be a part of your practice and how important is it to you. Great, thanks. Dr. Parker? Well, I might cross boundaries here a little bit related to the types of practices, but I've had the honor of, I mean, I did TMD for quite a few years and then incorporated sleep into it. And so I think as Dr. Osborne mentioned, he said, don't quit your day job. And I think his comment was transition. And that's what I did. I transitioned from TMD, added sleep to the TMD practice. And once the sleep practice got moderately bigger, I decided to shift and do dental sleep medicine full time. But I had a flow of patients and I had some relationships. And again, that's, you're in charge of the practice. It's your private practice that you're trying to grow. And all the comments that the Postles made are very true. You have to decide if you want insurance-based or fee-for-service. It's going to be easier with an insurance-based practice. The hospital-based practice, depending on how you do it, is more of a nine to five. It's less management because it's, depending on how it's structured and how many days a week you're there, you may be able to manage it more easily and you're working more closely with the sleep physicians. On the other hand, it has its limits. So I think as the Postles said, it really depends on what you're looking for and what you want to create. And I can tell you that there's nothing I've ever done in dentistry that was more gratifying than doing this. And I am so grateful for the opportunity I've had and feel so blessed to do this for all these years. And I tell my staff all the time how excited I am to get to the office in the morning. And who gets to say that? So I think it's because I've chosen the path in dental sleep medicine and the model that I wanted that I feel that way, I believe. And so that's why I think, as the Postles said, and what I'm saying is it really depends on what you're looking for and what you want to create in your career. Great, thanks. Dr. Osborne. So, you know, I was a general dentist dabbling for decades in this dental sleep medicine until I sold my practice, had a little discretionary funds to invest for the first time in my life, and of course started the mastery program with the ADSM. I wanted to continue practicing as a dentist and but focus more and more on DSM. I found it helpful to continue, as I've said, some general dentistry, especially with the hygiene recall exam. That's where I can catch those patients and get them started in the right direction, change their life. You know, I've really enjoyed watching DSM from almost its infancy to where it is today. We still have a long ways to go though. We've got to educate more of us. We've got to educate our medical colleagues, our patients. The momentum is shifting though in the right direction. Now, listen to me. I do not recommend going 100% into sleep dentistry just because you love doing sleep appliances, but now go all out if you love your patients and you and you passionately want to help them with their illness. We have the knowledge and ability as dentists to assist people to become happier and healthier and to lead more productive lives while achieving their highest potential and life expectancy. What a great opportunity, but our true value as clinicians lies not in what we do but in who we are, and for me, the path to success has been built on relationships. So I encourage all of you listening to reflect on each of these panel members here and their models that they've developed and see how we could, you know, realistically fit into your future because we need you. It's a worthwhile calling, and we need more people to fill the gaps, close the, you know, to research, education, and care. All of those areas are needed with sleep dentistry. So thank y'all for your time. Great, and lastly, Dr. Feigenbaum. Sure, I'll make this short. I live by these words, when opportunity knocks, open the door. I mean, I have, when I've done lectures and talking about different models and stuff, people have approached me and said, well, what if I do this? This doctor contacted me, he wants to do this. This, you know, everybody will not, I mean, people being approached with good ideas. I wouldn't be anywhere today if my sleep physician didn't come to me and say, why don't you learn about oral appliances and work in my office? That's how it all started, and then as far as the DSO I work with, they recruited me. I never looked for anything in all the years I've been doing this. I've opened those doors, so when that opportunity has come to me, I open the doors, and I haven't looked back. Thank you. Can I just make one more comment at the end here? I would strongly encourage everybody who hasn't gone through the Mastery program or become board certified, that that will build your credibility incredibly, and I strongly encourage you. It'll also build your knowledge base, which in the end, that's what this is all about, your ability to care for people.

dental sleep medicine

practice models

physician referrals

patient education

health system-based clinic

staff transition

insurance billing

patient volume

educational programs

board certification