Is Medicare Billing for Oral Appliances Worth the Time and Effort?

by Rose Nierman, CEO Nierman Practice Management

If you’ve been on the fence about increasing the presence of Oral Appliance Therapy (OAT) for Obstructive Sleep Apnea (OSA) in your practice and billing Medicare, consider this; Medicare is the largest health insurer in the US. By 2020, 64 million individuals will have Medicare. Medicare reimburses for OAT when the facility has a Durable Medical Equipment (DME) supplier license. Not only does being a Medicare DME supplier help patients who suffer from this potentially life-threatening condition, but Medicare billing increases your OSA patient pool significantly. A recent Nierman Practice Management (NPM) client survey revealed that well over 70 percent of NPM Dental Sleep Medicine (DSM) practices are properly enrolled to bill Medicare for oral appliances for OSA. In fact, our most successful dental sleep practices are enrolled to do so.
Why bill Medicare? Isn’t government coverage evil?
One of the reasons for the success of the practices I mentioned stems from the relationships these practices cultivate with physicians. Billing Medicare, even as a nonparticipating DME supplier (which we’ll discuss shortly), gives physicians the peace of mind to refer all oral appliance patient candidates to you, regardless of insurance type. A great way to earn the respect of your physician colleagues is to bill Medicare. A common misconception we hear is that practices believe they must accept a Medicare allowed amount as payment in full and not balance bill the patient anything, ever. This isn’t true! Of course, there are situations in which those rules apply, however, most of the dental practices that I’m referencing have made Medicare work in their practice by enrolling as a nonparticipating Medicare DME supplier.
What’s the big difference between participating and nonparticipating?
Being a participating supplier means “accepting assignment” on all cases or in other words – accepting Medicare’s allowable fee for OAT as payment in full, and not balance billing the patient for any amounts beyond your fee and their allowable fee. A nonparticipating DME supplier can elect to accept assignment or not on a case-by-case basis. The system pays 80 percent of the allowable fee (after a small deductible). If the patient has a supplement or secondary, that policy picks up the other 20 percent of the allowable fee. Another big difference to be aware of is when a nonparticipating DME supplier chooses to not accept assignment, the reimbursement check gets sent to the patient instead of direct-deposited into your bank account. Nierman Practice Management clientele typically sign up as nonparticipating DME suppliers and collect as a fee-for-service office with the reimbursement going to patients. Medicare’s reimbursement fee varies by location. Fees for your location can be verified by emailing
Is Medicare difficult to bill?
You may be surprised to learn that many NPM clients report that Medicare, while the application process may be a bit lengthy, is actually their favorite medical insurer to bill! One thing many practices we work with tend to particularly enjoy about billing Medicare is that a preauthorization is not necessary for oral appliances. When the patient meets criteria for coverage, there’s no need to wait around for permission to proceed! Another little-known fact about billing Medicare DME is that if you enter the supplemental insurance policy information on the primary claim, Medicare DME automatically forwards the secondary claim for you, so you file one claim and sit back. Also, you don’t have to send a packet of information with your claim as supporting documentation. Yes, that’s right! If you code properly, Medicare will release the payment, with the option to review later, so make sure your “ducks are in a row” with the right documentation on file.
Where do we go from here?
There are various steps to successfully enrolling as a Medicare DME supplier. The application can be confusing, so it’s helpful to have expert help not only to apply, but also to ensure that you follow Medicare’s DME guidelines.
Whether you are thinking of becoming a Medicare DME supplier or are currently a supplier, Medicare patients don’t have to be a loss leader. With lower cost Medicare approved appliance designs available, streamlined clinical handling, claim processes and balance billing, making it work for Medicare beneficiaries is common among NPM clients and can help more patients receive treatment.
If you have questions or need assistance, please contact us at 800-879-6468 to speak to one of our DME Oral Appliance Billing experts.

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