1. MEDICAL BILLING FOR DENTISTS
Presented by Megan Cheever, RN

2. 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

3. 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 $ 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.

4. 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

5. Insurance Verification

6. 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

7. 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**

8. 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…

9. CPT and ICD-10 Codes CPT Codes (Procedure Codes)
ICD-10 Codes (Diagnosis Codes)
E0486 – Appliance
New patient office visit (one time only)
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

10. 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

11. 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

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

13. 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

14. 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

15. QUESTIONS

16. Contact Brady Billing Phone: 844-424-5548 Fax: 214-975-2722
Insurance Verifications: