Successful Sleep Dentistry Article #5: A Sleep Dentist’s Guide to Begin Medical Insurance Billing
As dentists expand into dental sleep medicine and begin treating patients, taking the plunge into medical insurance may be necessary. Most dentists find it challenging because medical insurance differs from dental insurance and can be resource intensive, however, it does not need to be a daunting task. Once your practice is knowledgeable on how to handle billing medical insurance, you can start successfully treating the patients with oral appliance therapy (OAT) and growing your practice.
In this fifth article of the successful sleep dentist series, we interviewed Dr. Barry Chase, an expert dental sleep medicine dentist with over 10 years’ experience, who sees and manages more than 1,000 cases per year of medical billing at his office. We ask what he learned over the years of struggles and discoveries, and help you equipped with the basic knowledge necessary to start medical insurance billing.
How can my office prepare for medical insurance billing?
1. Confirm your National Provider Identifier (NPI) number.
Many dentists have this already, but it is necessary when dealing with medical insurance to have one, as well as a requirement of HIPPA. To get an NPI number, go to: https://nppes.cms.hhs.gov and follow the instructions on how to apply.
2. Order the Form CMS-1500.
Form CMS-1500 is a health insurance claim form required by various government and private health programs, including the Centers for Medicare & Medicaid Services (CMS) of the U.S. Department of Health & Human Services. Claims must be submitted on original, not photocopied, print versions of the Form CMS-1500 as they are printed in special OCR-scannable red ink to enable automated reading of information on the form. A sample is available at CMS website, and the printed forms can be ordered from U.S. Government bookstore, along with printing companies and office supply stores.
If you need more information, I will recommend you refer to the Fact sheet at CMS website.
What do I need to include in the claim?
You can start by checking the patient’s medical insurance plan.
There are the six must haves when filing a claim, regardless of the plan.
1. Form CMS-1500
o Health insurance claim form
2. Copy of the diagnostic sleep study
o The study must be read, interpreted, and signed by a physician who is a Diplomate to the American Academy of Sleep Medicine (AASM)
o At the end of the study there should be recommendations for therapy including oral appliance therapy (MAD – mandibular advancement device)
o Most insurance companies require the sleep study to be less than five years old
o Check the study is the diagnostic study, not a CPAP titration study
3. Physician’s prescription
o The medical insurance claim must have a prescription ordering the oral appliance signed by the physician. It can be on the traditional prescription pad form that a doctor would order medications, or a printed form generated from the physician’s office
o Any physician, whether a Diplomate to the AASM or not, can order an oral appliance
4. Copy of your clinical notes
o Intra and extra oral examination
o Occlusion and arch shape
o TMJ findings
o Chief complaint
o Treatment plan
o Treatment expectations
5. Copy of the CPAP usage document
To prove the patient is either non-compliant or non-tolerant to CPAP
5-1. Copy of the CPAP compliance log
o For the patient who tried CPAP therapy
o Many insurance companies want to know that the patient tried CPAP therapy and was non-compliant
o Again, check it is the CPAP non-compliant log, not the CPAP titration study
5-2. Copy of the CPAP non-tolerant form
o For the patient who has not tried CPAP therapy
o Must be filled out and signed by the patient with full signature and date
6. Letter of medical necessity from the physician, not the dentist
o This is not usually an essential requirement, but may ease the passage of the claim
Check out Whole You Support Tools for the medical insurance claim to make your preparation process even easier.
Do’s and Don’t of Billing Medical Insurance
Do take responsibility for collecting copayments and deductibles: The copayments and deductibles that the patient must pay must be collected by the dental office. There are hardship forms, which can be submitted on behalf of the patient, but these should not be over used. Not every patient who does not want to pay a copayment or deductible is a hardship case.
Do be prepared for more frequent auditing: Medical insurance companies audit much more frequently than dental insurance companies do. Ensure you know, and follow, the rules of working with medical insurance. Failure to do so could require you to return all the funds you received from an insurance company, possibly with interest and penalties. The potential risks for not following the rules are severe.
Do ask questions: Call and speak with a representative from the medical insurance company, he/she will be able to talk you through the insurance filing process and answer any questions you may have.
Do your due diligence when choosing to use a third-party vendor: Few aspects of moving into sleep dentistry are as daunting to the average dentist as taking on the medical insurance billing system. Many sleep dentists will use a third-party vendor to manage payments, since it is the most efficient way to manage the billing when the entire office is still not capable of managing on its own. If you’re determined to use a vendor to process your medical claims, do due diligence when choosing a vendor and remember that you may be responsible for any inaccurate or improper filing they do on your behalf.
Don’t insert the OA prior to filing the claim: Many companies will not pay the claim if the appliance is inserted prior to the claim filing. This can be an issue if the patient wants to prepay for the device, have it inserted and file for the claim at a later date.
Whole You is to Support You.
If you are a dentist who is interested in oral appliance therapy to add as a treatment option for your patients, or an existing sleep dentist interested in learning more, please call Whole You at 844-548-3385 (toll free) or visit https://www.wholeyou.com/medical-products/sleep-apnea-devices.
Whole You offers a full range of consumer marketing, educational and practice resources to support dentists and their patients as well as a variety of sleep appliances for sleep apnea patients with different conditions. Refer to Whole You Sleep Appliance Product Map for the further information.
Successful Sleep Dentistry Article Series
Other Sleep Apnea related articles