Welcome. I am Dr. Claire McGorry. I'm the moderator for this evening's private insurance Q&A webinar. I'm joined by our panel of speakers, Scott Craig and Drs. Erika Johannes, Rosemary Rogoty, and Alex Vaughn. To comply with antitrust laws, we are unable to discuss or address questions about fees or insurance reimbursement amounts. And finally, the AADSM does not endorse any services, 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 opinions expressed or communicated regarding product, device, or appliance during the webinar is solely the opinion of the individuals expressing or communicating that opinion and not that of the AADSM. Tonight's webinar is dedicated entirely to question and answer. So I'm going to just start out with our top one on the list, which is, what is the best way to determine a patient's financial responsibility for or appliance therapy if they have commercial insurance? And this is open to anyone, moderators. I'll jump in first. There's only one way. There's lots of ways to do that one way, but it's math. And unfortunately, you can do that a lot of different ways. There can be an Excel sheet that you've created a formula for. There can be software that will do parts of it for you. But realistically, you need to figure out the patient's, basically, their benefit status. You're going to use, basically, a few variables. It's their deductible remaining, how much money they have left in their deductible, and the percent copay, and then what the insurance allowable is. Now, the allowable is going to be the hardest factor of that to figure out. If you're in network, then you have a contract that tells you the allowable. If you're out of network, good luck. You might be able to go off of historical data. You might be able to go off of a magic eight ball. Insurance is only required to have a fixed allowable if you have a contract with them. Now, that contract can be a single case agreement, which is a little more advanced. But realistically, you're going to work it the same way you do dental insurance. I mean, it's the allowable. You subtract out the deductible from the allowable, the deductible remaining. If there's anything left, you take a percentage of that, and you add them together. It's very easy for me to say that. Written out is a little harder. It makes it a lot more easier to understand written out. But my recommendation, at least in my practice, when I started it, we used an Excel form that I created that you just put the three or four different variables you need, and it kicks out the answer. But I'm sure there's software available, too, that does it. We just do it all in Excel, personally. But long answer for a probably shorter question. I think Alex answered that really well. It is. It's basically simple math, and it just depends whether you're in-network or out-of-network, if you're accepting allowable, if you're going to balance bill. The one thing I would add is when you're obtaining financial responsibility for or determining it for the patients, is that you want to make sure that you're obtaining the benefits prior to patient arrival. Because again, if you're working with a third-party biller, as a lot of offices do, if you don't have in-house billing, a lot of them require, the third parties require 48 hours notice, maybe 24 hours notice. So you just want to be prepared and have that number ready prior to the patient coming in. Can I add something? There are some that will do a predetermination for you if you don't know what their allowable is. I mean, I'm in-network with a lot, but there are a couple of outliers or some really strange things that if they allow me to, I will submit a predetermination. And in there, I send them my fee. And it's kind of, it doesn't necessarily turn out a single case agreement, but they tell me what they're going to pay. Now that takes like six weeks. So it's not quick. And there are some companies who say predetermination is not recommended. That's nice. I'm going to do it anyways. But that's a way for an out-of-network to kind of get a a little better idea. Great. Thank you. So on to the next question. Does insurance or Medicare require sleep studies to be 12 months or newer? I can jump in on that one. So I think there's a lot of misinformation out there on this particular topic. In the local coverage determination from Medicare, there's no specific requirement that says that a sleep study has to be 12 months or less. So essentially a year. But there is a section in the standard documentation requirements under continued medical need that describes timely information, timely documentation. In that section, it states that timely documentation must be 12 months. But you know, this really only comes up for most providers when they're submitting for an oral appliance and the patient hits even similar and then they have to submit all the documentation. And then typically Meridian, which is the one that is hitting providers with this particular issue in the region's DNA, they're looking at the documentation and they're using this continued medical need criteria to say that the sleep study must be 12 months. The reality is that that's not the case. If the patient went in, saw a provider, the provider recommended the oral appliance, reiterated the fact that they have sleep apnea and signed off on the script, they meet the criteria. The issue is that Meridian is going to deny it regardless and you're going to have to appeal. So you're going to have to go through a variety of stages of appeal. And that can be a long, lengthy process for you to overcome the denial and eventually get it approved. But I can assure you that if you take this at least to the level of the administrative law judge, they are not required to go by the LCD in any way, shape or form, and they will overturn those cases. I can tell you that we've taken nearly 100 cases to the administrative law judge and we've won every single one of them at that level. The reality of that was that can take a very, very long time. I think the best way to answer that, that was perfect. It depends is going to be the answer that I would suggest, which is, or I should give clarification. All of our answers is great. There is no yes or no on most of these things. It's how much work do you want to do to get to the yes? And is it worth that work? So, for example, does like, this is a perfect example. Should you have a study within 12 months? Do you want an easy route? Yes. If it's within 12 months, you're not going to have any arguments. It's going to be easy. Do you need it within 12 months? No. What road do you want to go down? What's the best route for you? And if you're doing a few of these a month and you don't want to deal with the headaches, then just ask the patient to get a sleep study. I mean, that's a business decision, not a reimbursement decision. And Scott's exactly correct. If you want to go through the three, four, five levels of appeals to get up to the ALJ and let them go through it, you're probably going to win. Is it worth it or is the better answer to send your patient back for another sleep study? That's for you to decide in your referral network and your referral stream and the patient. That is a very difficult answer. The way I relate it, it's kind of like if Cary's extends to the cusp tip, do you need to do an indirect restoration? I don't know. Maybe, maybe not. Can you do it with direct? Can you do it indirect? It's very gray. There's easier answers. There's harder answers. What do you want to do? But Scott's exactly correct. It is not written in law that you need it within 12 months. Within 12 months, you're likely not going to have an issue. If it's more than 12 months old, you'll fight it and you'll probably win if you fight it. So, so I definitely agree with Scott. Very good answer. I just want to add just more informative that I did have Scott and I had had this conversation before. So it's like interesting. I was waiting for Scott to chime in. So, so I did have a Noridian rep did chime in and literally said, as long as the therapy was initiated, then you may use the existing study. If no therapy had been initiated, then a sleep study cannot be greater than 12 months old. But I do agree with what Scott was saying, because there's really nothing written. This was just more informative information that I got. And when I say therapy, that means CPAP or oral appliance therapy. It's therapy for sleep apnea, not necessarily OAT. And I think providers need to know too, that, you know, if you order another sleep study, just because they're not meeting criteria within these policies, that study that you're ordering is not medically necessary either. So, I mean, you're in a category 22 with respect to this issue. So I think the reality is that this particular criteria of continued medical need is being misused by Noridian, unfortunately, and they're denying claims improperly. So the reality is you can overcome that denial, but like everyone's saying here, it's an issue. It's going to take time to overcome it. Hopefully in a future local coverage determination, we can clarify this particular issue and make sure that we're not going to hit with this problem. Yep. Yep. Go ahead. I'm just agreeing. One more thing that I'm just going to add too, in a fever service type office, if you're doing that, oftentimes I will just let the patient know that it may not get covered. We may have a lot of pushback if we don't get another sleep study. If the patient says, I don't care, I don't want another sleep study, I don't want to do this again, except at least there's full disclosure, let them know that this might be tougher because I think full disclosure to the patient ahead of time, don't promise the world if you can't deliver it. Yeah. I haven't had pushback on a sleep study older than 12 months, but it's a great topic. It also comes up often when you might be redoing treatment that they've maybe been on in oral appliance, the oral appliance is broken. It's maybe four years old, maybe not the full five. You're wondering, do we need another sleep study? Can I use the existing? I think that's when I get the little gray as well. Got it. I think really we would all like a sleep study that is less than a year old in order to treat a patient and understand whether or not we're having an improvement in the patient's obstructive sleep apnea. But for purposes of this discussion, we're just talking about the criteria from the insurance and the reality is that's a misused criteria. I just realized that the question was, does insurance or Medicare? I was specifically speaking about Medicare, but the only insurance I see that does require a sleep study within 12 months or newer is I'm losing it. Scott, do you remember? There's one that I think it was, for some reason, I'm thinking it is, or do you happen to know, Claire? No, I don't. I mean, realistically, it's going to depend on your region and which insurance. I mean, ultimately, on the commercial side, you're going to have to look up your local policy. Because they're each, and honestly, the policies change rapidly. If you're talking UnitedHealthcare, they change every two to three months. If you're talking Aetna, it's typically one to two years. Blue Cross Blue Shield depends on your region. Humana is the slowest update. They don't have many policies well-written. But it's going to be in the policy if they have a limitation. Do they apply it or not and follow their own rules is a whole other question too, right? Again, within 12 months, it's going to be your safest. You're unlikely to get a denial within 12 months across the board. So PDAC appliance within 12 months, you're unlikely to get a denial from anything. Once you go outside of that, now you need to worry about policy and how much do you want to fight a denial. Okay, so moving on to the next question here. Can a cash fee for oral appliance therapy be different from the fee that a provider submits to medical insurance for reimbursement? No. That's the short answer. There's specifics to that, but no. Your fee is your fee. You can certainly offer an appropriate prompt payment discount. The Office of Inspector General has said that should be between 5% to 10% of discount on the price. So if you're offering 50% off, that would not be within the safe realm. So you can offer prompt payment discount. That is not a different fee. That is a discount on the money you receive, but the fee remains the same. So if you charge $5,000, you can offer 10% to 15%. So $5,000 to $750 off of that as the payment you accept, but the fee remains the same. If it's the same charge, same service, same situation. All right. Pretty simple answer there. Now onto the next one. How do you determine if an office visit should or should not generate a fee? I can take that one. CMS and the American Medical Association have guidelines for evaluation and management documentation and coding. So basically you have to follow those standards. And if you meet the criteria for, and they sort of break it down in terms of the types of visits that are billable, you have new patients, and then you have existing patient codes, you can bill based on medical decision-making, or you can bill based on time. And there are criteria for all of these. So depending upon which criteria you meet, you build a level of code that you can justify based on your documentation. So that's sort of, I think, my basic answer there. It gets a little more complicated than that with respect to those criteria, but that's sort of my blanket answer. Yeah. And I would also, I look at like the complexity of the case, how much time is involved. I kind of factor that in as far as whether it should be generating a fee. I fall in this scenario. So what we're realistically, we're dancing around the subject of global versus not global. In my opinion, and this is kind of how I teach it in the Mastery Program, insurance is paying you for using your brain. As dentists, we're used to being paid for using our hands, but in the medical world, you're paid for using your brain. So if I turn my brain on, it should generate a fee, is the general assumption. What I mean by that is if the patient comes in and they're having some discomfort with their appliance, my assistant deals with that. If she can't and I get involved, then there's a fee or should be. Now, when we're talking within global, now you're getting into the discussion of, are you adjusting the appliance? Are you providing medical management to the patient? We're getting to really a complex topic there. And my suggestion would be, unless you enjoy really the minutiae of medical billing, just don't generate a fee on that appointment. I personally believe you should be able to be paid for that. And I honestly think through appeal, you will get paid for it if your documentation is in the right place, but that's highly complex. But realistically, if I'm involved in the care, there should be a fee. If I'm not involved in the care, there usually is not. And that's kind of my breakdown because that's how medicine is too. If you call for a nurse, the nurse tells you something over the phone, they're not charging you. If you talk to the doctor, you're probably getting charged. There's a good cheat sheet with respect to billing on enmuniversity.com. Fantastic website. It's a great reference. So if you have questions on whether or not you meet the coding criteria for established or new patients, it really breaks that down really well into simple terms. It's a complicated issue. So it's nice to have a guideline for it. Okay. On to the next one. Is there software available to submit a claim or do I need to find a service? So my office, we do both. I use dental writer and they're automatically connected to Apex EDI. And then also I have a third party medical biller who will submit claims. And we will do our Medicare claims in-house as opposed to the rest of the private pay, we use a private party. I think nearly all medical software have the capability to submit claims and it's already generated in their software. Their websites, availability.com is going to be your number one website to use. Start there. Availability.com will give you benefit checks on most patients. You can pay to submit claims through them. You can sometimes submit claims directly to insurance through them. It's not easy or fun or a good way to do it, but it is a way and it's the most common way. It's kind of like using Google. If you work in a medical insurance, you know availability. Again, I wouldn't suggest you submit a lot of claims through them, but you can. But realistically, yeah, software is going to go through a clearing house and it's going to be pretty easy. Third party billing companies are just using medical software to do what you're asking them to do. You can do it all yourself. You're just paying them extra premium. Having said that, there's a value to that service, right? I mean, just like when you buy a car, you're paying the salesman extra to tell you about the car. So there is a benefit to third party billing services, but they're not doing anything magical. They're just using medical billing software that you could use too. Is there a fee with availability, Alex? It depends on the insurance. Some insurances you can submit with no fee and some you have to be on the availability plus super maxed option. It just depends on the insurance. And is it usually per case that you pay? It's going to depend on the clearinghouse. So some clearinghouses are going to give you a flat rate monthly. Some are going to give you a portion, you know, percentage or a, you know, five, 10 cents a claim. It's all going to be unique to what you negotiate. Availability is the name of the clearinghouse. Availability is a website. They use a clearinghouse that I believe they own. Most likely change healthcare is who they're using because that's the largest clearinghouse in the nation. But realistically, the days of mailing your claim to the insurances are fairly gone. You certainly can. If you're out of network, most of the time you can mail, it'll actually get processed a little faster a lot of times if you mail. But if you're in network, almost every contract requires you to use electronic billing and there you're going to have to go through a clearinghouse and how you access that is unique. But again, there are tons of softwares available, but availability.com is the most, I wouldn't say common, but the most, the best place to start. Let's put it there. Yeah. Demi-proof. Yep. It's a pain to use. There are a variety of clearinghouses that are a little bit easier than Availity and like have that flat monthly fee. But some, if some companies, if you are like in network with them, such as Blue Cross, like you can file claims right through their provider website. So if you're in network, you may not, depending on who you're with, like some of them you'll file that way and they'll process them instantly. Yeah. Which also means pay them instantly. Yeah. If you're doing a lot of claims, use a clearinghouse, a medical software that goes through a clearinghouse. If you're doing one to five claims a month, try and go direct with the insurance company or Availity. You know what I mean? One of those sites. But if you're doing, you know, more than probably 10 to 20 claims a month, I would start using a clearinghouse. Okay. When submitting to commercial insurance, what is the best code to use for office visits after the first 90 days? And do you ever have a reason to submit to insurance within the 90 day period? So I think the best code to use for office visits after the first 90 days is typically like 99213, 99212, depending on either time and complexity. And do I have a reason to submit to insurance within the 90 day period? Sure. If the insurance doesn't have like a global policy, I would use that. I would definitely use that to treat patients with like an office visit or an adjustment. I mean, technically you bill what you did, right? So like Scott said, you go to E&M University if you want to learn a quick way to do it, get really good cheat sheets on it. You can bill by time. So which code do you use? I always hate giving coding advice because you code what you did. Realistically, most of the time that is going to be a level three existing patient, 99213 or 99212. Level four or five are going to require a highly complex patient. And I always give the caveat in dental sleep medicine, we like to, we remind ourselves that sleep apnea is certainly a serious condition that can have serious health effects. But when you're looking at level three or four or five follow-up, you're talking about conditions that could result in harm to the patient rapidly without treatment, okay? And no one's dying of sleep apnea if they go one night without their appliance. So realistically, we're not talking about fours and fives most of the time. A highly complex patient where you're dealing with multiple diagnoses at the same time, sure, you can get to a four or five level, but you're going to start raising red flags if you're building a lot of fours and fives for sleep apnea alone as your diagnosis. And then you get audits. Okay, what do you say to a patient, what do you say to patients that call and ask, what is your fee? Well, I'll say, well, not me, but my front office will say, well, it depends on your insurance coverage, number one, because, and it depends what, how far you've met in your benefits. So we don't like to give a number out as far as fees, but we collect the insurance information ahead of time. And then we can always call the patient back and give them an estimation of what, first the consultation, but that's what we usually do. We just basically let them know, it really depends on your insurance. 90% of our patients have insurance. So I rarely have cash patients. Yeah, we don't have a fee we offer the phone. I mean, we tell them your insurance card will probably list your fee for your office visit. You know, certainly we can check on that, but in your visit, you know, the fee depends on what is recommended and what treatment is recommended. So you'll see the doctor, doctor will recommend treatment for you. And every visit ends with an estimate, you know, a unique estimate to you developed, you know, based on your unique insurance. And yeah, we don't have a fee we offer over the phone. Okay. With insurance deductibles on the rise, is it legitimate to charge a cash fee to patients and then not submit to their insurance carrier with their permission? Yes, as long as that cash fee is like we spoke about earlier. The patient can certainly, HIPAA is very clear that a patient has a right to control their information where it goes. So if a patient signs a document stating they do not want you to send to their insurance, it needs to be unique, a document. It can't be a blanket, never submit to my insurance. But if they sign a unique document stating that they revoke their authorization for their health information to be shared with their insurance, that's a unique document. So if they revoke their authorization for their health information to be shared with their insurance, you can charge them direct, but your fee can't be different than your fee. Again, you can offer prompt payment discounts that's reasonable, which is 5% to 15%. If you're playing games beyond that, I would probably run that by a healthcare attorney first. I would also be careful with that. I mean, my fee is my fee, is my fee. Sometimes they get the idea, they're like, oh yeah, don't submit it. And then they come back and they wanna submit it later. Like they get this idea where you've had a very specific discussion with them. And then they're like, oh, I'm gonna submit it myself. My insurance company says this, which is, yeah, great. Cause that joker on the phone has no clue what they're talking about. They will say, well, I can do this. Whoa, whoa, no, you cannot. You agreed. And sometimes that comes into like a PDAG and other things where like, I mean, you will sign up, down and sideways. And my consent to that says you cannot submit this to your insurance cause they will come back on the back end and wanna do it on their own. So I caution, even if you have it really well in writing, they still may come back and try to do it on their own. So be careful. Yeah, and it can get sticky with as far as what Erica was saying about if you make a certain device and their insurance requires a certain type of device being fabricated. And then if they wanna submit to their insurance and a different device is already made, yeah, it can get pretty sticky. I've had that happen before. Yeah, I would, you know, just to piggyback on that, I would certainly speak to an attorney anytime you're talking about reducing, you know, your usual and customary charge. You know, what are the scenarios in which you can do that? What are the rules, et cetera? I think all providers should be aware of those things. And I think, you know, there are different federal and state guidelines that come into play. So, you know, it's advisable to speak to your attorney in your state. Just to piggyback on that question, for those who may be new to this, who are not in network or have opted out of Medicare benefits, is there something specific to Medicare to say, I've opted out, I am not going to file on your behalf, signed written consent, I'm sure, the patient cannot also file after the fact? I mean, the patient can technically file. If you've opted out of Medicare, fully, I mean, actually filed your opt out, which, Dennis, by the way, do not have to. You don't have to opt out any longer. That was a possible thing in, I think, 2018, 2019, but they denied that. But if you have formally opted out and the patient tries to submit claim, Medicare will deny it as you're opted out and you have to have an individual contract with the patient. And it won't be provider responsibility. It should be processed as patient responsibility if you formally opted out. But generally speaking, Dennis are not obligated to be in Medicare Part B. It's voluntary for Dennis. Physicians are required to either be in or opt out, but Dennis are voluntary. If you are not registered or, so Medicare, we're talking Part B and DME, right? Part B, physician service for your office visits and DME for the appliance. On the Part B side, you do get some difficulty because there is such thing as a limiting charge where you can, if you are not in network, but you submit the claim, you are limited to how much you can balance bill, which is 15% above the limiting charge of 95%. So it's 107 and a half percent, I think is what it comes out to, of the Medicare allowable. On the DME side, you can balance bill full fee. So it gets complicated with Medicare, but realistically, if you're truly out of network, again, consult a healthcare attorney, but for the most part, it's the Wild West. I mean, as long as you're charging your fee, it's your fee, but as far as insurance requirements, if you're totally out of network, in most states, in most jurisdictions, once you've checked with a healthcare attorney to confirm it, you can bill your fee typically without needing a huge signature by the patient other than that they agree to your fees. And you do not have to submit. Correct. And again, once you've verified that with your healthcare attorney in your state, because remember state laws can apply to each person individually, not nationally. But yes, in general, you don't have to file claims for patients if you're not in network. With insurance deductibles on the rise, is it legitimate to charge a cash fee to patients then not submit to their insurance carrier with their permission? So this is all kind of along the same line. Yeah, I would say that. I think we probably got that one. Yeah. What would you say to a patient when they find out you're out of network? Is there something you can explain to them that will get them to consider staying with you rather than going with an unknown? You can file a network exception and potentially get that approved or a gap exception. Many people refer to it as that. If there's not a provider in your area, the insurance may approve that, and then you can take advantage of the patients in network benefit level. Yeah, beyond that, I'm not sure from a business perspective because I'm in network. So I'm not sure how to answer that. I'm at a network with almost all of our insurance companies, but sometimes they're in network is the same as they're at a network. So they match completely. It's not all the time. And sometimes you can just sit with them and show them the in and out for deductible, the cost share, whether it's 80-20, 60-40. And you can also just do the math with them. But also, I mean, if you're a diplomate, I think that helps because maybe a patient prefers to see someone who has the credentials. I think that helps too in showing data, showing your results as far as pre and post treatment with patients. I think all of that kind of has helped us be pretty successful being out of network. I think also getting to know your patient and what they value is going to be huge there. Not all patients value doing it on the cheap. So if you're out of network and you can charge whatever you want and you can spend more time with them, if they value you, you can say, hey, your network or your insurance would limit what I can do. I'm not limited to what I can do. Sometimes that's telling them, hey, I can give you a different device that your insurance doesn't limit me to. I can spend more time with you that I'm not limited to. So it's really going to depend on what your patient values. But if you ask them, what is the most important thing to you about your healthcare? And they say that it costs me $5, awesome. Then I'm probably not the person for you. And coming from a fee-for-service office myself, I would say that I do often say to patients that we submit for you. I think patients get good coverage on this. We'll look through it ahead of time. Let's see what your estimated is. And yeah, kind of do the math. It's harder to do the math when you don't know the reasonable customary fee that the insurance company is associating with this. So you're not really sure what number we're making a percentage of. But I find the more time I can talk to the patient as the doctor, again, yeah, get to know them and they value it to an extent. So, and if they don't, they'll let you know. Okay, if I'm not able to get in network with large carriers in my area, what strategies are remaining for a medical provider to want to refer to me? Would it help if I file the claims for the patient? I mean, I definitely think filing the claims for the patient and again, the concept of doing a network exception to take advantage of the patient's in-network benefits is very helpful. We're essentially 100% in network with the medical payers and there's a huge advantage to that. The referring physicians in our community around the Chicagoland area can trust that when the patients refer to us, they're gonna be seen by us. They can trust that when the patients refer to us, they're gonna be seen by a diplomat of the American Board of Dental Sleep Medicine who has a tremendous amount of experience at the lowest possible cost to the patient. So I think that's, in general, that's been a winning strategy for us. But if you can take advantage of some of these things, file a gap exception, take advantage of those patients in-network benefits, file the claim for them, anything that you can do, I think is a help to the patient because as we've talked tonight, there's a lot of nuance to medical insurance. It gets very difficult. It's hard for patients to navigate that space. So anything you can do for them is certainly beneficial. Anything you can do for your referring physicians, patience is definitely a win. So, and I would say too, that we have a payer where we're out of network and I can tell you that in the Chicagoland area, the out-of-network deductibles and the out-of-network co-insurance are very significant and very different from the in-network co-insurance and in-network deductible. I mean, it can be more than double the in-network co-insurance and deductible. So, it's a huge benefit to the patient to be able to file a network. So if it takes you a little time to file a gap and go through that process of getting a network exception, it's well worth it to your patient. Anyone else on that? Yeah, and I would just say as well, just full disclosure, make sure you have the conversation with the patient. If you're not able to get in-network, really look into their benefits, you know, and have a real discussion with them. And I find being out of network sometimes not pressuring them at all in the sense of saying, if you can find someone in a network, absolutely, I totally understand. This is what I'm providing X, Y, Z. And I think it depends on the area you're in, but I've had physicians come back to me and say, you know, I've never had a patient come back to me with issues about price. And I find there's less complaints about not getting coverage if they really know what they're getting into from the get-go. So I find full disclosure of everything and saying you're gonna do your best, but you know, you can't make any promises. It's helpful to not kind of over-promise and then under-deliver. But yes, I file claims for patients, of course, and that really helps. I'm just starting out with oral clients therapy. Is my first step to contact insurance companies to apply for in-network for medical insurance? I think your first step is do a business analysis, right? What do you want to do? So realistically, you're looking at very different business models. If you are doing, and this is opinion, right? I mean, this is opinion from where I live, where we're not discussing fees, but let's just say our lowest payer pays lower than probably most places in the US. And I'm sorry, not our lowest, our lowest payer and most common payer plays lower than most places. They pay lower than Medicare. And we're in the lowest Medicare region in the US. So we get paid very little by our most common payer. But you need to decide, do you want to be a high volume or low volume practice? And what do you want to fight? What game do you want to play? You determine what you want to do. If you're doing less than 10 appliances a month, don't be in-network. It would be just my first recommendation. In-network is a volume game. Now, if you want volume, be in-network. I mean, we showed up in our area, we said to our sleep docs, we're in-network with every insurance on the planet, and we got referrals left and right. So if you want to be high volume, be high volume and plan for that. If you want to be spending more time with your patients and spend a lot and a lot of kind of that energy that it takes to involve the filing a claim, explaining out-of-network benefits, doing gap exceptions, you have a lot more admin time on the out-of-network side. If you're filing for them, then do that. If you want to be fee-for-service and just have a fee, you charge and do nothing with insurance, do that. But your first step is to decide what your business model is. And then if you want to be in-network, deal with getting in-network, would be my suggestion. Also, maybe get a few under your belt. Yeah, you're just getting started. Figure out exactly what you want to do, or if you really like gray hair. I mean, I don't, but figure it out before you jump in and you're like, ooh, I didn't want to do that. Harder to undo it. So I have a lecture in the practice management course. I think it's on the website at the AADSM, and it talks a lot about in-network versus out-of-network. I mean, in terms of a business analysis, you really need to look at your payer mix. So you're looking at which payers are in your particular area, what percentage of the market they have, and then what is the reimbursement by payer? That way you'll sort of know what the mix of business you're going to have coming in. Like Alex was saying, there may be one payer who represents a very large portion of your payer mix that has a very low rate, and it may not be advantageous, obviously, to go in-network with that particular payer. So you kind of, you need to do your due diligence before you just go trying to find agreements with each payer. Plus, it's more than just the oral appliance. So we've been talking a little bit about evaluation and management, documentation and coding. There are many contracts that are being offered just on the DME side that exclude any office visits. And the issue with those types of agreements is that you're getting hit on your profitability every single time the patient steps foot in your office for any type of follow-up. So be careful about the types of agreements that you sign and understand what you're limited to in those agreements. Okay, the next question is similar, and I think maybe people are just looking for more specifics here from what we've already talked about. If I'm out of network and fee-for-service, how do I use a clearinghouse and upload documents when I'm filing or pre-authorizing for the patient? I heard there's a fee for that if you are out of network. I don't use a clearinghouse, so. I use a clearinghouse only to file. When I'm doing a pre-auth, it's usually happening over the phone or getting started over the phone. It has nothing to do with my clearinghouse. Now, I can, off of my clearinghouse, pull, the same way you can off of availability, like pull benefits off of there, but I'm not doing pre-authorizations there. Usually that involves a phone call, and some of them will, you know, any of the AIM ones will do it over the phone. Or other ones, you know, they get the party started and they say, here, fax your documents to this. But it doesn't ever, knock on wood, ever cost me anything to, I mean, I'm also in-network, but I don't do it through any in-network site. It's usually just, and it's not me, it's my people on the phone. Most states do not allow insurance companies to bill you anything to submit a claim or do a prior authorization. I can probably say every state, but I'm going to be safe and say most states. So the fees are likely clearinghouse fees that we all pay. If you use a clearinghouse, you're going to pay a fee. But the fee is usually pennies, I mean, if that a claim, right? I mean, it's bundles of claims. If you're not doing a lot of volume, then yeah, you're going to pay a higher fee, or you're going to do a monthly system where you're paying $5 a month, or $10 a month, or a certain number of claims. So that's all up to you. Unfortunately, I hate to say it that way, but it's up to you to do your job and look around. Availability is, like I said, a very safe way to do it. But there are other ways, other softwares, some charge per claim, some charge per revenue percentage. There's a hundred ways to do that. Your cost to submit a claim to an insurance company, realistically, should be pennies, if that. I mean, the most you should pay is the postage on a mailed envelope. That should be the most you pay to submit a claim. Preauthorizations, again, it can probably safely say every state has a law that says they have to prior authorize with no fee. Maybe not. But in general, their insurance can't charge you a fee to prior auth. They might not require it, though. So you have to remember that prior authorization is a... So I'm going to go into my mastery lecture here a little bit. But medical necessity and claim payment are two different sections of that insurance company. It's like two different companies completely. You're talking about Anthem and Aim, right? Even though Anthem owns Aim, Aim does the medical necessity determination. That's what prior authorization is. Prior determination is whether or not they'll pay the claim, which I have not run into, but certainly some places can. That's more common in dentistry. But that's going to be an insurance specific, whether they allow that or not. But most states require the insurance to allow you to call them to get information on that with no fee. One thing I'll say that we had had some issues with calling for prior authorization, if you are not a known provider for them, sometimes with your MPI, you come up under dental. So you call and it immediately sends you into the dental realm. And I have found sometimes the front has to call on the patient line to get through to say, I'm actually a provider, but you keep routing me to dental and the patient doesn't have dental benefits, but I'm calling on their medical benefits. So sometimes the provider line won't get you there with your MPI. You have to kind of backtrack a little bit. Or you have to interrupt the rep before they transfer you. Right. Yeah. Yep. I would encourage that. I would encourage every dentist to do at least 10 to 15 of these calls themselves before you ask your staff to. Learn what the pitfalls are going to be, because the best thing on these calls is you give them your MPI number. First, you give them your name. Right. Because that's the first thing they're going to ask you is your name. Then you give them the MPI number and then they pull up the doctor and they realize you're the doctor. And like it is amazing how the tone of the conversation switches, but you at least have dealt with those hurdles on the front end. So you know what your staff's going through. I don't think anyone should ever ask their staff to do something they haven't done. And that includes billing insurances and calling on prior offs, calling on prior determinations, calling on benefits. You need to go through this yourself to see what it's like. And sometimes you're on hold for a long time. Exactly. It's your admin day. You're always on hold for a long time. You need to live that because you need to understand why your staff call. When you ask your staff to do something and they give you pushback, you need to understand why. Because of course, we're busy. Everyone's busy, but we're running between room and room. We don't see them sitting on hold for 20 minutes or an hour. You need to experience that yourself. And it should be your first 10 to 15 claims. Okay, if I'm so never mind that we've done that one. What are the pros and cons of being in network with commercial insurance companies like Blue Cross Blue Shield, Aetna, Cigna, UHC, Tricare, etc. And I think Scott has pretty much explained that already, if anyone wants to go into any extra detail, he eloquently explained it previously, the benefits to it. It just makes the yes easier. Sometimes. That's the bottom line. If you know, the words I say to my patients are I don't like financial surprises, myself, I don't want to give you a financial surprise, I'm going to try to give you the best number. So being in network, I mean, I know almost down to the penny, what they're going to pay, sometimes exactly to the penny. And that's a benefit. And then the yes, because a lot of times they're paying less out of pocket. I'd say those are the two main advantages. And I think the majority of the reasons providers aren't in network is either one, the network is closed, or two, the rate from that particular pair is low to the point where they don't want to join the network. So I mean, those are really the only reasons I usually see patient or providers outside of the insurance network. It's a business decision. It's 100% business, you need to be a business owner. It's not about being a dentist, it's about being a business owner. Do you want do you, you need to do the business analysis, the cost benefit analysis of this, you need to know what your average reimbursement is going to be across all your payers and decide is that a good business strategy with the volume you'll get from in network versus a higher margin out of network and a lower volume? What do you want? I mean, I can tell you our average patient, patient portion, not patient fee, but our average patient portion last year was $225 and 74 cents, because I was in network. And when I can go to a sleep physician and say your patients on average will pay $225 and 74 cents. That refers a lot of patients to me a lot. That's that's the volume game. Or do you want to play a higher margin, lower volume game and what what fits in with your strategy? I only do sleep. I don't do general dentistry. I'm not trying to manage both at the same time. So you've got to do the business analysis. But also you guys didn't touch up on the cons of being in network. I guess the only thing I would think is you cannot balance bill because you have a set fee, right? And then another con would be when if you do get audited, you just have to make sure that you're following their guidelines, the agreement that you guys had agreed to with the commercial insurance payer. I'll tell you, if you file the claim for your patient, you're responsible for audit as well. So even out of network, if you file the claim, if you sign the claim form, you are responsible for audit. Now, if your patient, if your fee for service and your patient files the claim, you're not responsible on the audit side. But well, again, check with your health care attorney in your state and all of that. But if you file the claim for your patient, you are responsible and they can take that money back on audit and your patient can file a lawsuit against you. Are they going to? No, but they can. Oh, Claire, I think you're muted. I am. Other than refusing to accept Medicare Advantage patients, how do you deal with the insurance company saying the patient can't be billed? Am I still muted? No, you're good. I'm just laughing at this question because I deal with this all the time. How do you deal with the insurance company saying the patient can't be balance billed even if it's an ABN, even if an ABN was signed? The fee that MedAdvantage allows around 800. I take MediAdvantage, so I don't know if you guys want to answer this. Try and politely explain to your patient that their insurance company is defaming you or file a defamation lawsuit against their insurance or deal with it. Unfortunately, insurances often put on the EOB that it's provider responsibility and that you can't balance bill them. If you're not in network and your state law and the insurance plan, again, there's lots of asterisks, but insurances are notorious for stating that you cannot balance bill them when you actually have the legal right to balance bill them. How you manage that is a business decision. In my office, it's going to depend on the issue. If we're talking a $100 balance, I'm probably going to write that off and just deal with it. If we're talking about an entire claim, yeah, we're going to be dealing with that from a legal system, not against the patient, more often against the insurance company and involving the state. Okay, what are the pros and cons of using a third-party biller? How about in-house billing? You kind of touched on this already. Well, a third-party biller can be a great way to get started, but know that they're going to take a cut and you're going to do most of the work, all the work, minus hitting the button. 99% of the work is on you. Yeah, so you're getting all the documents, you're uploading everything, you're doing all of it, and you're going to care more about that than they ever will. I mean, when the claim gets paid, they get paid, cool, but they don't have the urgency maybe that you do, especially if you're just getting started and it's real important to you to get paid for these. They're not going to have that same urgency that you will on your own. I mean, I think it's also about expertise. If you don't have the expertise, obviously hire out for that expertise, but if you have it, great. I've seen many of a provider who think that they have the expertise who go about trying to do insurance in-house only to find out that they have claims that aren't paying, they're not appealing anything, their billers don't know what they're doing. So I think it's an important decision. A competent biller is worth their weight in gold, and an incompetent biller will cost you a lot of gold. Yeah, I feel like the pros of using a third-party biller is that, like Scott said, they're knowledgeable. They may have a network of people that they actually already know, so it's easy for them to submit claims perhaps, and they know the space, and they may have a person or a rep that they talk to usually on the phone, so they have that knowledge. I'd say the cons, like Eric has said, there's a lot of back and forth emailing because we do have that. And yeah, you're paying more money up front, or just, I mean, as a percentage. The benefits may not be timely when you get them, and the third-party biller may or may not appeal your claims. I mean, I would hope that they would, but sometimes they don't. But I think an in-house biller, if you're doing a lot of, if you're seeing a lot of patients, I think it's a huge benefit in the sense that you have control of your claims, and you can make sure that they're submitted timely. Again, it all comes down to business, right? I mean, what are you paying for? You're paying, realistically, you're paying about the same. Whether you pay through failure or you pay through expertise, you're paying the same. So in-house, you're going to pay through failure. Like, you are going to mess up. You're going to have claims that don't pay because you didn't do the right thing. A third-party biller is going to overcharge you for what they're doing. And where do you want to, you know, because they're paying, you're paying for expertise. You're not paying for what they're doing. Submitting a claim is stupidly easy. Appealing a claim is easy. Sending in prior authorizations is easy. Knowing how to do it is hard. Knowing what words to use is hard. And so you're paying for expertise. You're not paying for a service, if that makes sense. So my opinion is most times start with a third-party biller and plan on transitioning it in-house as you go along. And you start learning the lingo. You start learning the pitfalls. You start learning the hurdles. The fee that you get charged is always going to be what you negotiated out. Medical, typically on the medical side, you're seeing lower single digits per cent. On the dental side, you're often seeing lower double digits. You're paying for unique expertise in dental sleep medicine that you aren't going to get on the medical world. And then as you transition, maybe move to a medical system where you are paying lower rates for someone that's just submitting your claims and then bring it in-house. I think the other reality, I mean, just to say, I think it's a disservice to the medical billing companies to say that it's as simple as hitting a button and a claim is out there and easy-peasy, it's gone. It takes someone time to do all of this stuff. We talked about the kind of time it can be, it can take to be on the phone and do a prior authorization or check benefits. Someone has to do that. It's either going to be your staff or it's going to be, you know, the company that's doing billing for you, staff. So there's a cost to doing all of that. The question is, do you want to bear that cost internally or do you want to offload that cost to a third-party billing company who has, again, you know, the expertise? Especially if you can get a third-party billing company that has an expertise in dental sleep medicine, it can make a lot of financial sense and you can avoid a lot of the repercussions of doing this the wrong way. You know, there are timelines on all of these claims. Once you submit a claim, if it's not paid properly, you know, it starts o'clock and there's an appeal process and there's a certain number of days and, you know, there are different levels of appeals with all the payers and so forth. So, you know, you really need someone who's competent to do that. And I think like others said, one of the things that I see with third-party billing companies is they won't necessarily go after, you know, some of the smaller components of your revenue. Maybe the office visits, the other things that you might, you know, that might generate a significant amount of revenue for you if you're doing volume. So, you know, I mean, for simple, for E0486, for the oral appliance itself, you know, it can be, it can be, you know, a great service for you. If, you know, if you're doing some of the other things, you know, maybe it's in question, depends on the company that you're working with too. Yeah. Like I said, you're paying for their expertise. You're not paying for their time, you're paying for their expertise and knowledge. And there's a big difference, you know, not all third-party billers are the same. So check who you're looking for first, because there are some good ones, there are some not so good ones. But even within really good companies, you will find they've got newbies. Everybody's got new people. So, you know, somebody who's been doing it for 30 years and somebody who's been doing it for 30 minutes, very different results. And I've had both. So, you know, but I mean, I will say, if you start that way, pay attention. Pay attention to what's going on because you can, I mean, for me, my personal story was I got irritated and learned how to do it myself because I was irritated. And so but pay attention because they can teach you as you, you know, as not that they're going to sit down and have a lesson with you, but watch what they're doing. If you've got a good billing company, watch what they're doing. Learn. We might have time for just one more question. We're almost on the 8 p.m. mark. If you are a fee for service, if you are a fee for service, do you need to submit insurance to the patient? Are there pros and cons to this? Do you still have to call for pre-authorization? It depends. Unfortunately, the answer, right? I mean, do you have to call for pre-authorization? It can depend on the insurance itself. Which insurance plan? Are there pros and cons? And do you submit? I'm in-network. I personally think in-network's great for volume, bad for margin. If you're doing low volume, don't be in-network. Be out-of-network. Be fee for service. The submitting claims for your patients, I think, is a strong liability that I personally wouldn't like. I don't live in the fee for service world, though, so I don't want to speak to that. But just know that if you are signing a claim form, you are responsible for that claim. That's the only thing I want to highlight, because I think a lot of us are thinking that we don't flip the claim, flip the CMS 1500 form over and read the back of it, because that's what you're agreeing to when you sign it. That's the only thing I'm going to add on that. If you submit for your patients, you are agreeing to a lot of things, whereas if your patients submit for it, they are agreeing to it. So the liability shifts. But that's, again, I'm not fee for service, so I can't really give you the pros, but that would be my thought. I would say the pros to filing for the patient is you get more doctor referrals, because the last thing physicians want is a lot of paperwork for their patients. I think as far as assigning the benefits goes, if you're going to charge a fee up front and have them pay up front, obviously make sure that all the benefits is assigned to the patient. So anything that they get reimbursed is paid directly to them, and it doesn't touch your hands at the office. And then as far as preauthorization goes, I would say, yeah, it depends entirely on the insurance carrier, and many times there's no preauthorization for out-of-network, and sometimes there is preauthorization for out-of-network. So you still, if you want to get an estimate of cost for the patient and do them that courtesy, you still have to call or check benefits online and see if a preauthorization is required as an out-of-network provider. And when you call, just specify out-of-network provider. And many times they say no, out-of-network provider or preauthorization isn't required. And you then just submit either by mail or however you submit as an out-of-network provider to them. But I would say, and the cons is it takes time. It's not not time-consuming. You don't have to agree to the fee of the insurance company, whatever fee discussion you have there. You get to charge your own fee, whatever that may be. But if you don't file for them, I have found many physician referrals start to dwindle if you're not doing the paperwork. So, yeah, there's definitely a balance there. Okay. I think that's all we have for tonight, at least all we have time for. So I'd like to thank our speakers for their participation. We all appreciate your generosity in participating in tonight's webinar.

private insurance

Q&A webinar

panel of speakers

fees

insurance reimbursement

antitrust laws

services

products

AADSM

opinions