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Key to Successful Billing Oral Sleep Appliances to Medical Insurance

Oral Sleep Appliances June 2, 2021

As more dentists move into procedures to aid sleep, questions about how to bill oral appliances to medical insurance are becoming more prevalent. Oral appliances for obstructive sleep apnea (OSA) have no specific dental codes, and it’s almost unheard of for dental plans to pay for these products. However, medical insurers often reimburse them. Here are some effective tips for dental practices in billing medical insurance. 

OSA Billing for High Deductibles and Policy Limitations

It is between the patient and their insurance provider if the patient has a high deductible. For certain patients, having the oral appliance add to their deductible is also a plus. If the health company has a continuous positive airway pressure therapy (CPAP) clause or a Policy Limitation, an oral appliance case would be quickly disqualified from billing to medical insurance.

Policy Limitations

Other insurance companies only cover OSA appliance therapy every three years. So, if a patient had treatment and the insurer paid for it a year ago, the insurance would not pay for another oral appliance treatment until the time requirement is met. In this scenario, the patient will have to wait for their appliance or pay cash. If they don’t want to wait for the insurance time limit, they can use financing like CareCredit to get the appliance now.

Your dental office is not responsible for the coverage provided by the patient’s medical policy. It is your duty to manage the patient and assist them in improving their general health and quality of life. Begin billing medical insurance as a service you offer to your patients in order to reduce their patient section.

CPAP Requirements

If the patient’s medical insurance includes the use of a CPAP, the patient must use it for at least 30 days before exploring other options. This treatment is much more difficult, requiring the patient to jump through additional hurdles.

The Key Is Proper Documentation 

Proper and accurate documentation is crucial to successfully bill medical insurance for OSA. The minimum requirements are as follows:

  1. Sleep test results

A copy of the sleep test is a necessary part of your documentation.  A polysomnogram (PSG) or a home sleep test (HST) are two types of sleep tests. Some insurance companies have limitations on the types of tests they would cover. For instance, before Medicare can pay for PSG, it now requires that home sleep tests be used first. A number of sleep test machines are also available.

Some diagnostic devices are not FDA cleared. For this reason, a few payers refuse to accept them as diagnostics. As a guideline, you can use the same sleep test findings that the board-certified sleep specialist used to interpret them. As a consequence, the findings of your sleep test will fit the perception. To be eligible for treatment, certain payers recommend that a patient have a certain AHI. As a consequence, it’s important that the patient’s AHI be clearly stated in your sleep test reports. These will be repeated in the clinical notes, which we will go through in more detail later.

  1. Diagnosis from a board-certified sleep specialist

To cure sleep apnea, a patient must first be diagnosed. Only a board-certified sleep specialist may make this diagnosis. The sleep specialist will score the outcomes of the sleep test to decide the seriousness of the patient’s apnea.

It makes no difference if the sleep test was conducted in a lab or at home. An interpretation is a term for the scoring and diagnosis process. The board-certified sleep specialist interprets the results, confirms the diagnosis, and then documents the extent of the patient’s sleep apnea, as well as treatment guidelines. Diagnoses never actually expire, but only a few insurance providers have a time limit or expiration date from the date of interpretation, as long as it is before the treatment.

  1. The dentist’s clinical chart notes

The Subjective, Objective, Assessment, and Plan (SOAP) notes can be a source of anxiety or irritation in offices. In a SOAP note, you’re describing the patient’s symptoms, the diagnostic details you’ve gathered (which would include the sleep test as well as the severity interpretation), and the treatment recommendation you’ve made. You’ll also make notes about the patient’s comfort, updating home instructions, and the delivered titration position of the appliance.

In general, dentists perform intra- and extra-oral exams as part of their sleep appliance assessment. You want to make sure a patient is a successful candidate before treating them. Prior to care, you should perform a comprehensive examination of the jaw, including a range of motion and muscle palpation, and ensure that any jaw or tooth conditions your patient has been reported. A patient might complain after six months that your oral appliance has harmed their jaw joint or teeth. You would be able to prove that the patient had certain previous problems by having good documentation.

  1. CPAP affidavit

Not all payers require a CPAP affidavit, but enough of them do that we recommend you collect one on every patient. This affidavit does not prevent them from later getting treated with a CPAP machine. The affidavit simply states that they have been given both treatment options, and they are choosing the oral appliance for whatever reason they give.  They will sign the affidavit and include any detail about why they feel a CPAP wouldn’t work for them. Again, reiterate this to your patient, this does not prevent them from getting a CPAP at a later date. It simply states they choose the oral appliance at this time.

  1. Presenting Medical Billing To The Patient

Now you know exactly what documentation you’ll need to bill an oral appliance to medical insurers. From here, you’ll need a copy of the patient’s medical insurance card, as well as full benefits, to check to see if the patient is covered.

You’ll learn if they have a remaining deductible to meet and if they have any plan exclusions during the verification of benefits (VOB). if they have a history of using continuous positive airway pressure (CPAP) or if there are any other explanations why the device might not be covered. You won’t know the allowable at this stage since they don’t release a fee schedule unless you’re a participating provider.

Don’t let possible roadblocks stand in the way while you learn more about the method of billing medical insurance for oral appliances. Don’t be afraid to give medical billing to your patients as a payment option. Keep in mind that the ultimate aim is to lower the patient portion while increasing case acceptance.

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