Special Article 2, Issue 9.4
Emerging Models: Consider Various Billing Models to Help Patientshttp://dx.doi.org/10.15331/jdsm.7268
Mitchell Levine, DMD1; Kevin Postol, DDS2 ; David Schwartz, DDS3; Michelle Cantwell, DMD4; Becky Fox, DMD5; Nelly Huynh, PhD6; Paul Jacobs, DDS7; Omar Mahmassani, DDS8; Rosemarie Rohatgi, DMD9 Kevin Wallace, DMD10
1Department of Orthodontics, Saint Louis University, St. Louis, Missouri; 2Sleep Disordered Dentistry, Ballwin, Missouri; 3North Shore Family Dentistry, Skokie, Illinois; 4Wellspan Pulmonary and Sleep Medicine, Lancaster, Pennsylvania; 5Fox Dental, Ltd, Lemoyne, Pennsylvania; 6Faculty of Dentistry, Universite de Montreal, Montreal, Canada; 7Upper Peninsula Sleep Dentistry, Escanaba, Michigan; 8Omar Mahmassani, DDS, Frederick, Maryland; 9San Diego Sleep Therapy, San Diego, California; 10Midwest Dental Sleep Center, Chicago, Illinois
Our AADSM predecessors fought hard to get oral appliance therapy (OAT) reimbursed by Medicare and many commercial medical insurers. Although billing medical insurance for OAT is a customary practice, a successful dental sleep medicine practice can be developed around a variety of other billing models.
Understanding medical insurance and billing are often cited as reasons dentists hesitate to get started in dental sleep medicine, but they do not need to be impediments. Several billing methods qualified dentists can consider are described in the next paragraphs. As you read the assorted options, keep in mind that no single model may meet your practice needs. The demographics of a practice will often dictate one or more models that work best for the patients served, and those are even likely to change over time. Regardless of the billing model, open conversations with patients and referring providers about your billing practices will help them understand the value of your services.
MEDICAL INSURANCE BILLING FOR OATFor patients with commercial or government medical insurance, knowing that OAT is covered by their plan can be an important element in the treatment decision. Similarly, physicians may prefer to refer and work with qualified dentists who are able to bill the patient’s insurance. For those willing to navigate in-network enrollment, medical billing claims processing, or gap exceptions, billing medical insurance may be a viable practice model. Some dentists prefer to hire an independent third-party for aspects of medical insurance billing, such as medical credentialing, preauthorization, claim submission, billing and periodic auditing. If you are considering using a third party, we encourage you to ask the right questions before outsourcing this important function.
Billing Commercial Medical Insurance as an In-Network ProviderCommercial insurers may cover OAT under their medical policies for OSA treatment. The process for obtaining an in-network contract and the willingness to negotiate on reimbursement issues varies significantly by insurer and is based on geographic location, market share of the insurer, and other factors.1 The American Academy of Dental Sleep Medicine (AADSM) offers members a template letter that can be used to support in-network application requests. Each insurance policy is different and commercial insurers update them frequently. We encourage dentists to review policies from the insurances you bill on a regular basis and before billing an insurer that is new to you. This helps ensure that you use the documentation and claims processes appropriate to each insurer.
Gap Exceptions from Commercial Medical InsuranceWhen in-network contracting with medical insurance is not feasible, waivers may be available from some commercial insurers. A gap waiver allows an out-of-network provider to provide the patient’s OAT at in-network rates. Gap exceptions are granted at the discretion of the insurer and are most likely to be approved when only a few OAT providers exist in a region and the dentist can make the argument that patients do not have good access to in-network providers for OAT. Gap exceptions may be a viable alternative to in-network billing for some dental sleep medicine practices. The AADSM offers a gap waiver toolkit for members that describes the process and includes templates for requesting gap waivers.
Medicare and Medicaid BillingOAT is covered by Medicare under the durable medical equipment (DME) benefit. If you work with a patient population that is covered by Medicare or with referring physicians who are Medicare providers, you may want to bill Medicare. To submit claims, the dentist must enroll as a DMEPOS supplier with the Medicare program. Step-by-step information on enrollment is available in the AADSM’s Medicare Billing Enrollment online webinar. Enrolled dentists agree to accept assignment for all Medicare patients and are then prohibited from balance billing. Or enrolled dentists can choose on a patient-by-patient basis whether to accept assignment or not. When you choose not to accept assignment, you are allowed to balance bill that patient. Medicare limits the types of oral appliances that can be reimbursed and sets reimbursement limits based on the region of the country in which the patient lives. The AADSM provides members with additional information on Medicare in the Reimbursement Guide and on the website. OAT may also be covered by Medicaid. These policies are set on a state-by-state basis, so you should be sure to check the Medicaid policies within your state prior to providing services.
DENTAL INSURANCE BILLING FOR OATEffective January 1, 2022, the ADA implemented three HCPCS CDT codes for oral appliance therapy.
D9947 custom sleep apnea appliance fabrication and placement
D9948 adjustment of custom sleep apnea appliance (includes titration)
D9949 repair of custom sleep apnea appliance
These codes establish a pathway for dentists to use CDT codes to document and bill dental insurers for oral appliance therapy. Although dental plans are not obligated to cover these codes, dentists may want to request dental insurers to cover some or all of these codes as part of their contract negotiations. Additionally, these codes set up the opportunity for dentists to utilize billing practices like other nonreimbursed dental codes in your practice.
PREPAYMENTAnother billing model that should be considered is prepayment, often referred to as fee-for-service. In this billing model, patients pay the dental office in full for OAT, either through a one-time payment or by an installment payment agreement arranged in-office or through a third-party financing company. This is usually without any subsequent insurance reimbursement. This model may provide benefits such as allowing you to select the appliance that is appropriate for each patient without being limited to an insurer’s list of approved devices and allowing you to reassess your fee structure as you reduce expenses associated with navigating insurance contracts, preauthorizations, claims, appeals, etc. In a 2022 polling of newer AADSM members, 76% offered a prepayment option.
Adopting a fee-for-service model requires you to be clear with your potential patients and referral sources about the value you bring as a provider of high-quality, patient-centered care. As an additional level of service to patients with commercial insurance, the dentist may offer to submit a claim and assign all insurance benefits to the patient. Whether the practice chooses to submit commercial insurance claims for patients under this prepayment model, the dental practice should be prepared to provide documentation as required for insurance reimbursement.
To implement a prepayment model for Medicare beneficiaries, dentists must not be enrolled as Medicare DME suppliers. Unenrolled dentists must enter a private contract with each patient who has Medicare coverage. The contract documents that the patient must pay the dentist directly for OAT and that neither the dentist nor the patient will submit claims or receive reimbursement for the therapy. A sample contract is available on the AADSM website.
ADDITIONAL CONSIDERATIONSAs you navigate these various billing models, it is important to keep patients and referring providers informed. The patient’s financial obligation and the specific services included in the fee should be made clear to the patient. With any billing model, patients should be reminded that flexible spending accounts and health savings accounts can be used to pay for OAT.
Dentists should also consider common principles of ethical billing, such as avoiding overbilling and duplication of benefits.1 Dentists should charge similar fees to patients regardless of their insurance coverage. Many insurance plans require cost sharing by the patient, usually in the form of deductibles, copayments, and coinsurance. Waiving the patient payment portion of these fees without informing the insurer is considered overbilling, a form of fraud, because it makes the overall fee look higher to the insurer than it is.
Many commercial insurance plans, both medical and dental, will have coordination of benefits provisions that dentists should follow. Dentists should not bill both medical insurance and dental insurance for the same services and should carefully follow the coordination of benefits provisions. In cases where the fee can be billed to multiple insurers, the combined reimbursement should not exceed the dentist’s full fee for OAT.
As we continue to evolve our practices to meet the public burden of obstructive sleep apnea while continuing to provide optimal patient care, we have to recognize that billing is not an insurmountable impediment to providing OAT; however, it is something that will require open and honest conversations with patients and referring providers, so everyone is aware of how you bill and why it allows you to provide the best care possible.
Just as with the first article in this series, we recognize that billing models are affected by many factors, including but not limited to state regulations, geographic location, relationships with referring licensed medical providers, and dentists’ capacity to provide OAT in relation to other areas of their practice. We encourage you to continue the discussion on the AADSM’s online discussion forum using the thread titled “Emerging Models.”
CITATIONLevine M, Postol K, Schwartz D, Cantwell M, Fox B, Huynh N, Jacobs P, Mahmassani O, Rohatgi R, Wallace K. Emerging models: Consider Various Billing Models to Help Patients. J Dent Sleep Med. 2022;9(4).
- Principles of Ethics & Code of Professional Conduct. American Dental Association. Accessed September 13, 2022. https://www.ada.org/about/principles/code-of-ethics.
SUBMISSION AND CORRESPONDENCE INFORMATIONSubmitted in final revised form September 13, 2022.
Address correspondence to: Mitchell Levine, DMD; Email: email@example.com
The authors declare no conflicts of interest.