How to Bill Medical Insurance for Oral Appliance Therapy (Must-Read for Dentists)
Yes! Dental offices can consistently get great medical insurance reimbursement for oral appliance therapy (OAT). Implementing some simple tried and true strategies can certainly help your patients say “yes” to treatment and help your practice to become more referral friendly at the same time!
It’s a shame that dental teams have helped in letting others outside the dental world believe that oral appliances are not covered by medical insurance and that the treatment is an expensive out of pocket paid option. The fact of the matter is totally to the contrary. We would like to help everyone understand that dental teams can get great medical insurance coverage for OAT when they work with tried and true medical insurance strategies. In this effort, we hope that we can get more medical teams on board to reach out and find dental partners who can help their patients who prefer oral appliances.
It’s really counterproductive when a dental office asks patients to pay for this treatment in advance. This “up front pay in full” philosophy usually comes about when the dental team has not sought the proper help and has not learned how to assist patients to make this treatment option more affordable by maximizing medical benefits.
As a dentist who’s been involved in dental sleep medicine for almost 10 years, I’ve worked diligently with our physician counterparts to promote oral appliance therapy and to help bring more dentists onto the sleep health team. Almost every time I have a conversation with a medical doctor about appliance therapy for OSA, I hear, “Well those appliances are expensive,” or “They’re not covered by medical insurance.” I think a big part of this comes from comments that patients make to their physicians when they return to the medical office. I think we are often missing a great opportunity to demonstrate how well we can do clinically with oral appliance therapy because we are often putting up financial barriers to treatment acceptance and obstacles to referrals in the first place.
So what can we, as dental teams, do to help patients and physicians see that OAT truly is an affordable treatment option? First, we can educate ourselves to competently verify and check medical benefits so we can minimize the amount of out of pocket we ask patients to pay in advance. Most dental offices are accustomed to the routine of checking eligibility and benefits for dental insurance. We’ve seen that the dental team can learn to do the same with medical benefits by using skilled coaches or can outsource dental sleep medicine verification of medical insurance and medical billing, either to the same successful endpoint. It’s really a case of patient friendly + physician friendly equals more potential growth for your dental sleep medicine practice.
Whether the dental team has a formal checklist for the dental insurance process or knows it by memory, when working with medical carriers, you should create a formal written checklist, along with protocols. We provide this vital tool for offices we are working with. When checking medical benefits, it’s the small omissions that can end up as big problems later on.
Don’t skip steps. Start with verifying eligibility, documenting unmet deductible, and asking if a pre-authorization is required. Remember that in the medical world in-network and out-of-network unmet deductible may not be the same. Most of the time the dental team is out of network, so make sure you are getting the correct information. The need for a pre-auth can be triggered by code or by the fact that the treatment cost is over a certain dollar amount. You need to cover both in your checklist. Medical carriers are not forgiving when an oral appliance requires a pre-auth and you fail to do so. Thinking about getting a pre-auth after you have delivered an appliance is too little, too late. Nothing looks worse in your patient’s eyes, or can bode worse with a referring medical office, than an explanation of benefits from a patient’s medical insurance company saying in effect, “We didn’t pay this claim because your provider did not follow the rules.”
Let’s have a short discussion of two other pitfalls for the dental team.
Situation one: A patient has out-of-network (OON) benefits in their medical coverage, but this is accompanied by an OON deductible that is significantly higher than the unmet in-network deductible. When this occurs, it’s time to think about getting OON or a “GAP” exclusion. This is actually a one-time contract you can obtain from the medical carrier to treat the case as in network. In this situation, the patient would only be subject to the lower in-network unmet deductible. You can ask the agent of the medical carrier to help you navigate this process. While not always the case, be aware that this can take 30 days (or longer) as the carrier actually is preparing a formal contract for you on a case-by-case basis.
Situation two: Billing on paper. I actually find this to be one of the biggest problems in medical billing that dental offices create for themselves. Face it, no medical office bills on paper. When you submit a paper claim that has to be reviewed by human eyes, you are at a distinct disadvantage in many ways. Reviewers of paper medical claims have rarely seen the codes we are submitting for dental sleep. You are therefore more likely to be delayed when the reviewer requests additional documentation or the claim is just outrightly denied. There is additionally no way to verify that a paper claim is in the system even if you send it by certified mail. Solution? Bill electronically. I doubt anyone reading this article submits their dental claims on paper, so why would you do that for medical claims? Electronic claims can be immediately tracked, are less subject to scrutiny, and are paid much more readily and quickly. Submitting a claim electronically doesn’t lessen your obligation to make sure you have the proper clinical documentation. The medical carrier still has the right and will often ask you to provide clinical records as a follow-up. When you submit an electronic claim, you are certifying that you have all the medically necessary records and documentation in your clinical record. I can’t overemphasize that you must have the proper medical grade clinical documentation to substantiate what you bill.
A simple solution for the dental team that desires to be more patient and physician friendly, but does not have the desire or the staff to handle these tasks, is to practice dental sleep medicine and outsource these insurance-related tasks. Help is available, but make sure you seek help that has years of experience to have mastered the process.
Marty Lipsey, DDS, MS, is president of MedicalBillingforDentists.com and owner of Dental Sleep Med Systems Inc. One of his personal goals, and a goal of his team, is to help dentists remove this barrier to patient acceptance and physician referrals. If you would like more information about services in building the dental sleep medicine area of your practice, e-mail Info@nullMedicalBillingForDentists.com.