medical insurance for obstructive sleep apnea

Download Medical insurance for obstructive sleep apnea

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  1. 1. Medical Insurance for Oral Appliance Therapy for Sleep Disordered Breathing
  2. 2. Ellen Crean, MS DDS PHD Owner at Triton Medical Solutions LLC Partner at Kosmo Technologies LLC Disclosure:
  3. 3. Course Objectives: Understand the difference between medical/dental insurance1 Operating your practice as insurance medical model vs. fee for service2 Medical insurance for oral appliance therapy for obstructive sleep apnea3
  4. 4. Commercial Insurance4 Medicare5 In network vs. out of network contracts6 Course Objectives:
  5. 5. Operating billing from your office vs. utilizing the services of a billing company7 Course Objectives:
  6. 6. Dentists Billing Medical Insurance 1. For services within their scope of practice 2. Different than dental insurance Insurance can not deny payment to a provider based on type of provider, if it is a covered benefit of the plan under the scope of practice of that provider.
  7. 7. How Differs from Dental Insurance Patient is not limited to small amount of coverage per year1 Covered benefit codes linked to specific diagnostic codes2 Many more steps to payment3
  8. 8. Medical Model vs. Fee for Service Model Pros What MDs & patients want Makes treatment more affordable More case acceptance More referrals Cons Have to abide by insurance company rules Multiple steps to get paid Work with allowed amounts Wait for payment Benefits of switching to medical model as DDS Pros Charge what you want Get paid right away Less work Cons MD: less referral used to patients being covered by insurance Less case acceptance More money for patients Patients go to in network provider Benefits of staying with fee for service model as DDS
  9. 9. Patient Perspective of Medical Insurance that insurance recognizes. In the medical model the opposite is true covers and put added value on treatment Patients tend to do what insurance
  10. 10. Dental Services that can be Billed to Medical Insurance
  11. 11. Sleep Breathing Disorder Treatment with Appliances Covered Services Exams X-rays Rhinometry Pharyngometry Appliances
  12. 12. Medical Insurance terminology to know Provider NPI Rendering NPI Referring NPI ICD-9 CPT HCPCS DME Participating Provider Non Participating Provider In Network Out of Network Deductible OOP Gap Exception Network Insufficiency LOA EOB EFT Pre-Auth CMS-1500 HIPPA 5010 Modifiers Clearing House Tax ID DME DME POS Electronic Billing ERA
  13. 13. Types of Insurance You Will Encounter Types of Medical Insurance Commercial Medicare Medicare Replacement Medicare Supplemental Medicaid Private Plans Independent Payers for Commercial Plans
  14. 14. Medical Insurance Coverage for Oral Appliance Therapy for Sleep Disordered Breathing Oral appliances: Oral appliances are a covered benefit on medical insurance and Medicare plans They are covered under DME POS (custom durable medical equipment) They must have diagnosis of obstructive sleep apnea or upper airway resistance syndrome to be covered Most insurance companies require electronic billing
  15. 15. Steps for Getting Paid Eligibility, Benefit, Deductible Check Pre-Authorization Gap Exception (if necessary) Electronic Bill EFT or Payment (EOB) Appeal (if necessary)
  16. 16. Clinical Documents Needed for Pre-Authorizations Diagnostic PSG Report (diagnosing apnea) RX from MD who has seen the patient Documentation of CPAP trial or letter from MD stating why CPAP not recommended for patient GAP exception request (if necessary) Narrative describing appliance with FDA # or PDAC # NOTE: Some insurance companies are now requesting invoices from lab as to what manufacturers retail price is
  17. 17. Pre-Authorizations Most insurance companies require pre-authorization for E0486 Some will give pre-authorizations for a specific date of service, others will allow a 3-6 month window when service can be performed In order for insurance to pay, patient must be seen for treatment within valid pre-authorization time frame Must wait for pre-authorization and GAP exception before seeing patient in order for them to be valid benefits Pre-authorization and GAP exceptions can take up to 12 business days to obtain
  18. 18. Commercial Insurance (HMOs & PPOs) HMOs Only in network benefits Usually lower deductibles Most have own copays PCP usually needs to initiate pre-authorization and referrals Can get GAP exceptions if no in-network providers PPOs In & out of network benefits Variable deductibles Some have co- pays Patient has choice of doctor to see Most will approve GAP exceptions (some will not)
  19. 19. In-Network Benefits vs. Out-of-Network Benefits In-Network Benefits Higher percent of coverage ex: 80/20 Usually lower deductible Allowed amount or negotiated fee schedule Payment goes to provider Out-of-Network Benefits Lower percentage of coverage ex: 60/40 Higher deductible Patient responsible for difference between billed amount and allowed amount Payment goes to patient
  20. 20. Contracts In-Network LOAs GAP Exceptions
  21. 21. In-Network Benefits vs. Out-of-Network Benefits In-Network Benefits Higher percent of coverage ex: 80/20 Usually lower deductible Allowed amount or negotiated fee schedule Payment goes to provider Out-of-Network Benefits Lower percentage of coverage ex: 60/40 Higher deductible Patient responsible for difference between billed amount and allowed amount Payment goes to patient
  22. 22. Medicare Oral appliance covered under custom DME POS Dentists can obtain a provider/supplier DME POS contract with Medicare (application, site visit & must follow DME supplier standards) DME divided up into 4 jurisdictions in US Jurisdiction D has set fee of: $1,290.00
  23. 23. Medicare Standards Medicare has standards set for billing oral appliances Must be billed for and provided by a dentist Wants global code E0486 to cover all treatment from time decision is made to do appliance and 90-days after delivery Must use a PDAC approved appliance With Medicare you are either: 1. Opted Out (need informed agreement from every patient 2. Participating provider 3. Non-participating provider
  24. 24. Benefits of Medicare No pre- authorization required Maintain clinical records in patients chart (if requested) Payment by EFT Payment generally in account by 15 days of billed.
  25. 25. Medicare and Supplemental Insurance Medicare will automatically send to supplemental insurance for payment electronically Medicare has yearly deductible (around $140.00) Can bill Medicare patient for remaining 20% if no supplemental insurance Most Medicare patients have supplemental to cover remaining 20% Medicare pays 80% of allowed amount
  26. 26. Internal Office Billing vs. Billing Service Company In-Office Staff to learn new process Time on phone or computer to do eligibility & benefits checks as well as pre-authorizations Sending clinicals to insurance companies Must be electronic so need software and clearing house setup Tracking claims In-Office Resolving appeals Evaluating EOBs Appeals & denials Communicating with insurance companies Contracts, applications and follow- ups Billing Company Know how to register you with insurance companies for efficient payment Takes everything out of your hands Know how to deal with insurance companies Has relationship with insurance companies Will get contracts for you Manages all accounting related to billing
  27. 27. Internal Office Billing vs. Billing Service Company Lots of staff time frustration Office Billing Less staff time Claims Paid Billing Service Company

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