MEDICAL BILLING FOR DENTISTS Presented by Megan Cheever, RN

What is Medical Billing? The practice of submitting claims to insurance companies in order to receive payment for services provided to a patient by a doctor Claims include patient information, medical insurance information, provider information, CPT codes (procedures performed), diagnosis codes, authorization numbers, and medical records Starting October 1, 2015 medical insurance has converted from ICD-9 to ICD-10 for a more detailed way to show insurance companies what the patient is being diagnosed with

Medicare If you are not a Medicare DME provider then you CANNOT accept Medicare – These will be cash patients If you do accept Medicare we do not have to verify benefits. Medicare has a $183.00 deductible and covers at 80%. The patient will be responsible for 20% unless they have supplemental insurance. DME providers can only bill for the oral appliance. In order to bill for office visits you must also be a Medicare Part B provider.

Insurance Verification Insurance verifications give us specific details including deductible amounts, coinsurance percentages, and out of pocket maximums The insurance company can provide us with the amount that the patient has met towards the deductible and out of pocket maximums We are also able to obtain whether or not preauthorization or predetermination is required for specific procedure codes Reference numbers are obtained in case we have any discrepancies throughout the process

Insurance Verification

Gap Exceptions GAP exceptions allow out of network providers to be considered in network for a specific time and a specific treatment when no in network provider can offer the same services GAP is not allowed on all policies GAP is typically allowed for 90 days / New GAP would have to be initiated beyond that time frame Claims with GAP exceptions are typically paid incorrectly and require review GAP may be initiated by many different ways (per policy) Provider / 3rd party biller In network provider / PCP provider Member initiated

Preauthorization / Predetermination Preauthorization and/or predetermination is required by many insurance companies for the oral appliance They are similar in that the insurance company is reviewing if the proposed treatment is medically necessary Preauthorization: Typically gets an authorization number that needs to be included on the claim when submitted Typically is valid for specific dates of service Requires clinical information to be submitted to insurance for review Does NOT guarantee payment once claim is submitted Typically a decision is made within 15 business days Predetermination: Does not have specific dates that treatment needs to be completed The "approval" letter will state that E0486 is covered by this plan Does not have an authorization number to include on the claim when submitted Typically can take up to 30 business days **Think of these as your permission to treat....if you do not have approval....DO NOT DELIVER**

ICD-10 BCBS will approve which appliance?? BCBS requires predetermination…except when its through AIM…then it is preauthorization…. BCBS will approve which appliance?? Aetna says POS must be home…. We won’t get paid by Cigna for HST… Premera says temporary appliance…

CPT and ICD-10 Codes CPT Codes (Procedure Codes) ICD-10 Codes (Diagnosis Codes) E0486 – Appliance 99201-99204 New patient office visit (one time only) 99211-99214 Follow up office visit 70355 Pano 95800 Home Sleep Study G47.33 Obstructive Sleep Apnea G47.30 Sleep Apnea, unspecified G47.9 Sleep disorder, unspecified R06.83 Snoring

Medical Diagnosis Initial visit for a patient that comes to you with no sleep study Unspecified Sleep Disorder Snoring Fatigue Visits for a patient that has a sleep study, or returns with a study and diagnosed with OSA Obstructive Sleep Apnea ONLY

HOW TO DETERMINE PATIENT COST PATIENT WITH NO INSURANCE / NO APNEA PATIENT WITH NO OUT OF NETWORK BENEFITS PATIENT WITH INSURANCE CASH FEE CASH FEE DEDUCTIBLE HIGHER THAN CASH FEE DEDUCTIBLE LOWER THAN CASH FEE CASH FEE *COLLECT DEDUCTIBLE *FILE TO INSURANCE *WRITE OFF REMAINING BALANCE *COLLECT DEDUCTIBLE AND COINSURANCE BASED OFF YOUR CASH PRICE *FILE TO INSURANCE *WRITE OFF REMAINING BALANCE

PATIENT WITH INSURANCE Cash Fee: $2500 Insurance Fee: $6500.00 Insurance pays 60% DEDUCTIBLE HIGHER THAN CASH FEE Deductible $5000.00 DEDUCTIBLE LOWER THAN CASH FEE Deductible $1000.00 CASH FEE $2500.00 *COLLECT DEDUCTIBLE ($1000.00) *FILE TO INSURANCE ($6500.00) *WRITE OFF REMAINING BALANCE *COLLECT DEDUCTIBLE ($1000.00) AND COINSURANCE BASED OFF YOUR CASH PRICE $2500 – $1000 = $1500 X 40% = $600.00 Total collected $1600.00 *FILE TO INSURANCE $6500.00 *WRITE OFF REMAINING BALANCE

The Life of a Medical Insurance Claim Patient registration and charge entry Claim Transmission Claim submitted to a clearinghouse Preliminary screening of claim Conversion to insurance specific format Dispatch to insurance companies Preliminary screening Pre-edit / Audit Claim Adjudication Communication of decision Payment or Denial and EOB sent to provider Follow up from office about incorrect payment or denials

What will 3rd Party Billers require from you? Copy of photo ID and medical insurance card Patient phone number and address Affidavit of CPAP intolerance Referral from MD / Prescription Sleep study (within last 5 years) Letter of Medical Necessity (when requested) Epworth Sleepiness Scale Mild AHI requires comorbidity History of stroke Hypertension Excessive daytime sleepiness Ischemic Heart Disease Insomnia Mood disorder Brain Injury Claustrophobia

QUESTIONS

Contact Brady Billing Phone: 844-424-5548 Fax: 214-975-2722 Email: Megan@bradybilling.com Insurance Verifications: insurance@bradybilling.com