4 Axioms for Medical Insurance Success

by Randy Curran and Kyle Curran

I’ve lived in the medical billing world for nearly 20 years. That’s 20 real years – not the 2 weeks that might feel like 20 years these days. I’ve seen a lot of changes with coding, policies, and procedures and had the good fortune of seeing many practices flourish. I’ve also learned a lot about what not to do. There are 4 axioms – statements that are established and self-evidently true – about medical billing.

Axiom #1 – Medical Insurance is Not a Magic Wand

Some practices register for our services with the mindset that since they hired a billing company, their job is done. They falsely believe that every patient is going to get 100% coverage, and they won’t have to put forth any effort. Although the former is occasionally true, it is not going to be the case for at least half of your patients. Why, you ask? The majority of dental practices across the country are out-of-network providers. Practices in states like Michigan and Illinois have much easier situations, as their lowest paying PPO carriers allow over $2,400 per treatment and automatically process claims as in-network. Other states such as Alabama and Wyoming have a high penetration of BCBS PPO plans that allow less than $1,000 for oral appliance therapy (OAT). You may want to reconsider if you were thinking about packing up your practice in Wyoming, MI and heading out west to open a new DSM practice in Cheyenne, WY.

Like so many other things in life, the key to success is being a student of your circumstances. You must have a solid understanding of how medical insurance is going to work with patients in your state. Once you understand and accept this, you will be able to set the correct expectations of insurance coverage. This will allow you and your team to build case presentations accordingly.

Adopt this way of thinking – insurance can help supplement the cost of the treatment; it is not the alpha and omega. If presented well, a practice will move patients forward, even when the patient has to pay out of pocket for most of the treatment due to a high deductible. If you explain that the cost is $1,500, but most of that will apply to the patient’s deductible, and possibly even the family deductible for the remainder of the year, the cost is more palatable as there are collateral benefits to my payment for treatment. Sometimes you have to seek the silver linings.

Axiom #2 – Play by the Rules

This is *NOT* your home rules version of Monopoly that always seems to be slightly different from the way your uncle or best friend plays it. In the game of medical insurance, you must play by the rules whether you like them or not. If you don’t, you definitely won’t pass go, you won’t collect $200, and you might even go to jail. It’s OK if you don’t like it because you didn’t create the game, my friend.

“I’ve billed dental insurance for 30 years and this is/isn’t how insurance works,” is a common refrain sung by newer clients, and it’s way out of tune. You may think the Epworth score is ridiculous or that the STOP-BANG has a higher positive predictive value, but the insurance carriers don’t care about your opinion. If you want your pre-authorization approved or your claim paid, you must adhere to their polices. Also, contrary to popular belief, the billing service isn’t making up these rules to make your life harder.

Axiom #3 – Implement a Solid System

To play by the insurance carrier’s rules, it’s paramount that you establish a consistent, repeatable workflow. We advise all clients to be mindful of state-specific dental board regulations, policies of the insurance carriers most often encountered in the practice, and the recommendations of relevant professional organizations. If you want a program to run smoothly, it will always begin with a solid foundation.

Different insurance carriers require different documentation, and state dental board guidance varies across the country as well. If you are a dentist in NJ, NY, OH, GA, and perhaps a few others (dental boards are currently reviewing this as I’m writing), you cannot order a sleep study. It must be ordered by a medical doctor; the practice can either refer the patient to a local MD or use a system that encompasses a telemedicine visit prior to a home sleep test’s (HST) delivery.

On that note, if you are a Medicare provider, your patients will also need a face to face visit with a sleep physician prior to the sleep study. Under no circumstances can the HST be delivered by the dental practice, as it is a conflict of interest in Medicare’s eyes. Speaking of face to face requirements, United Healthcare updated their dental sleep policy in August 2019 to also include a face to face visit. This face to face visit does not dictate that it must be done prior to the sleep study, though is does state that it must be done with an MD or DO trained in sleep.

Axiom #4 – Patience Is a Virtue

Paraphrasing Proverbs, “patience is a virtue”, which is especially true when implementing a dental sleep program poised for long-term success. DSM is like a vineyard. There is seemingly endless toil with no immediate payoff. But once the roots have been established, you will see many years of prosperity that exceed your wildest dreams.

Too often, new DSM practices expect that within the initial 6 months they’ll treat 10 patients per month and add an additional revenue stream of $30,000 or more. This is not reality for most practices. Out of more than 1,000 practices I’ve helped, I can count on one hand the practices that have experienced that level of immediate success. Even in good-paying states like MI or IL, it takes time to get you into the insurances’ systems for payments. Some of your first payments may take 3-5 months with certain Blue Cross/Blue Shield plans. The carriers are in no hurry to pay out claims.

Maybe you’ve elected to go in-network if your gap approvals have been denied and you’ve found it difficult to close cases. This will require patience, too. It typically takes 6-10 months to obtain a dental sleep medicine in-network contract. Patience, my friends, patience.

Using medical insurance to help your patients move into treatment can be a great service to your community and your practice. Ensuring that you have a streamlined, integrated system for managing telemedicine, HST, and medical billing will position you for long-term success and ensure you’re compliant with state, payor, and professional rules and regulations. Lastly, being patient with the process and setting realistic expectations of insurance payments guarantees that your practice will do it right and realize the fruits of your labor for seasons to come.