How to Bill Medical Insurance for Oral Sleep Appliances

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Start Billing Medical Insurance For Oral Appliances 

As more dentists begin to perform their role in dental sleep medicine it raises a lot of questions on how to bill oral appliances to medical insurance. The key to successfully billing oral appliances to medical insurance is having the proper documentation and tools.

Sleep apnea is a medical condition and is not covered by dental insurance. This points us towards medical insurance for coverage. Medical insurance is another form of payment, but is dependent on the patient’s individual diagnosis and insurance coverage benefits.

When talking to your patients about utilizing their medical insurance benefits we recommend you offer it as a courtesy. This helps you set clear expectations with the patient, and can alleviate the pressure on your office. It is completely unknown how much of the treatment will be covered, and coverage is dependent on several variables. As a dental provider, you are simply offering medical billing as a way to reduce the patient portion. You can compare it to the common phrase “under promise, over deliver”.

High Deductibles, Limitations & Medicare

If the patient has a high deductible, that’s between the patient and their insurance company. They chose a plan with a lower premium, and as a result, they have a higher deductible. Having the oral appliance apply to their deductible is also a win for some patients.  If the insurance plan has a CPAP requirement or Policy Limitation, that quickly disqualifies an oral appliance case from being billed to medical insurance.

CPAP Requirements

It is rare, but if the patient’s medical insurance has a CPAP requirement it asks that the patient use a CPAP for 30-45 days before they can look at alternative treatment. This process is a lot more involved and has more hoops for the patient to jump through. 

Policy Limitations

Some insurance will only pay for OSA appliance treatment every 3 years.  So if the patient received treatment and it was paid by the insurance 1 year ago, the insurance will not pay for another oral appliance treatment until the time requirement has been satisfied. In this case, the patient would need to either wait or pay cash for their appliance. They could utilize financing like CareCredit if they want to proceed with the appliance rather than wait for the insurance time requirement. 

The patient’s coverage with their medical insurance is not the responsibility of your dental office. Your responsibility is to provide treatment to the patient and help them improve their quality of life and overall health. Start looking at billing medical insurance as a benefit you provide to your patients in an attempt to lower their patient portion.

Medicare

If you find yourself in a position where you have a medicare patient. You can learn more by reading our post Billing Medicare For Dentistry & The Types of Providers.

The Key Is Understanding Documentation 

Successfully billing medical insurance for an oral appliance is greatly dependent on documentation.  The following are the minimum requirements:  

  1. Diagnosis of Sleep Apnea by a board-certified sleep specialist
  2. Copy of the sleep test results
  3. Written order or prescription for an oral appliance, written by a medical physician
  4. CPAP affidavit
  5. Clinical chart notes from the dentist

Let’s break these down in a little bit more detail.

Diagnosis of Sleep Apnea by a board-certified sleep specialist

In order to treat a patient for sleep apnea, they must first be diagnosed. This diagnosis can only come from a board-certified sleep specialist. The specialist will take the sleep test results, score them, and determine the severity of apnea the patient has.

It doesn’t matter if the sleep test was done in-lab or at-home.  This scoring and diagnosis process is called an interpretation. The board-certified sleep specialist does an interpretation, confirms the diagnosis, and then puts into writing the severity of the patient’s sleep apnea as well as treatment recommendations. Diagnoses never technically expire so very few insurance companies have an expiration date or time limit from the date of interpretation, as long as it’s prior to treatment.

Copy of the sleep test results

You will need a copy of the sleep test. The sleep test can be an in-lab study known as a polysomnogram or PSG, or a home sleep test known as an HST. Some payers do have restrictions on what type of test they will accept. For example, Medicare now requires home sleep tests to be used first, before they will pay for PSG. There are also a variety of types of sleep test machines.

There are a few select payers who will not take certain machines as diagnostic, even though they are FDA cleared for this purpose.  As a general rule, you want to use the same sleep test results that were interpreted by the board-certified sleep specialist. This way your sleep test results will match the interpretation. Some payers require a patient to have a certain AHI in order to be eligible for treatment. So it is important that your sleep test results clearly state the patient’s AHI. You will also reiterate these in the clinical notes, which I will cover in more detail shortly.

Side Note

As a side note, even though sleep test results technically never expire, we do not recommend working off of old data. For example, if your patient was sleep-tested 10 years ago, you do not want to use that sleep test as your baseline. How do you know if the patient’s apnea has gotten more severe?  What are the chances that their health and their sleep are the same today as they were 10 years ago? 

As a general rule, we like to have sleep tests that are within the last 12 months. With the cost of home sleep testing being so affordable, there’s really nothing stopping a patient from getting retested for more current information. 

Written order or prescription for an oral appliance, written by a medical physician

Since dentists are technically the DME or durable medical equipment provider of the oral appliance, you must have a written order or prescription from a medical provider in order to treat the patient. This can come from any medical provider or physician that the patient has seen. It often comes in the form of an actual prescription, and it will list the procedure code on it, E0486. It should also include the diagnosis code, G47.33. Again, remember this prescription does not have to be written by a board-certified sleep specialist.

For example, a patient had a sleep test done 6 months ago in a different state. They were diagnosed with sleep apnea but never received treatment. Fast forward to today and you identify that they are an untreated sleep apnea patient and recommend oral appliance therapy. 

If they can get a copy of the sleep test with interpretation from the board-certified sleep specialist, they do not need to return to that specialist for the prescription for the oral appliance. They can simply take the interpretation to their primary care doctor or local physician who can write the order or RX. Here is an example of what a prescription looks like.

CPAP affidavit

Not all payers require a CPAP affidavit, but enough of them do that I 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.

Clinical chart notes from the dentist

Soap notes are an area that can cause offices to have fear or frustration. All you are doing in a SOAP note is explaining what symptoms the patient has, what diagnostic information you have collected (which would include the sleep test as well as the interpretation with severity), and what treatment recommendation has been made. When you deliver the appliance, you will also add notes about patient comfort, reviewing home instructions, as well as the titration position you deliver the appliance in.

As a general rule, dentists do intra and extra oral exams as part of their evaluation for sleep appliances. Before you treat a patient you want to make sure they are a good candidate. You should do a thorough evaluation of the jaw, including range of motion and palpation of muscles, and make sure that you’ve documented any jaw or tooth conditions your patient has prior to treatment. The last thing you want to do is have a patient come back to you after six months of wearing an oral appliance, and tell you that you have somehow affected their jaw joint or their teeth. If you have proper documentation, you will be able to show that the patient had those conditions prior.  For additional information on soap notes, please watch Your Guide To Understanding Soap Notes.

Presenting Medical Billing To The Patient

So now we’ve covered documentation in detail and you know exactly what you need in order to be able to bill an oral appliance to medical insurance. From here, you are going to collect a copy of the patient’s medical insurance card and complete a verification of benefit to see if the patient is eligible for coverage. During this VOB, you will find out if they have a remaining deductible to be met, if they have any plan exclusions. if they have any CPAP history or reasons that the appliance may not be covered. You will not know the allowable at this point, because unless you’re a participating provider, they do not make a fee schedule public. You will present treatment to your patient as if you’re going to collect 100% of your fee from them and give them an estimate based off your verification of benefit of what appliance coverage might be. For information on this and the next steps in creating a pre-authorization please watch How to Simply Bill Sleep Appliances to Medical Insurance

As you start to better understand the process of billing medical insurance for oral appliances, don’t let potential obstacles get in your way. Don’t be afraid to add medical billing as an additional payment option for your patients. Remember, the overall goal is to decrease the patient portion, and increase case acceptance.

Devdent is a certified distributor and trainer for the Imagn Suite. 

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Crystal May

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