Game Changer

by Randy Curran and Kyle Curran

You have heard a cacophony of opposing views about everything from appliances and billing protocols to fees and accreditation; from sleep testing and sleep physician engagement to purple mountains majesty and amber waves of grain. No matter where you are in your Dental Sleep Medicine career, you have experienced some confusion about, well, about nearly everything.

Ten years ago, pioneers in the Dental Sleep Medicine (DSM) field adroitly persuaded Medicare to recognize the importance of Oral Appliance Therapy (OAT) and they subsequently drafted a comprehensive policy. As is customary, private insurance carriers followed suit and consistent medical insurance reimbursement became commonplace. A significant barrier to treating patients was removed, and the number of dentists providing OAT grew significantly. So why, after a decade, do most DSM practitioners, despite their gusto and expertise, only treat one or two patients per month?

1. Greed

With insurance coverage for OAT came exploitation. Dentists were uncertain about what their fees should be. A cadre of willing hucksters took the podium at many weekend courses, and sickeningly took advantage of a system that hadn’t yet defined usual and customary allowable rates. In California, more specifically Los Angeles, it was like 1849 all over again. It was a veritable gold rush replete with the same ilk of con artists and unsuspecting marks that you saw back then. These charlatans showed slides featuring EOBs of $9,000 while encouraging attendees to charge upward of $15,000 for treatment. Permit me to put that into perspective; Medicare allowed approximately $1,300 for OAT in California. Unfortunately, that is rather low for quatlity treatment. However, the answer is not to bill an order of magnitude higher. This cash grab created a stereotype that many physicians still hold regarding DSM clinicians. Of course, this doesn’t apply to you, but shaking stereotypes is difficult. Just ask a Cubs fan.

2. Physicians

Unfortunately but understandably, many of your physician counterparts bought the stereotypes of DSM practitioners as greedy gougers of the system. This has triggered frustration in the majority of dentists – professional providers with a focus on patient care and wellness. As Mark Murphy, DDS, deftly demonstrated in the last issue of Dental Sleep Practice, many physicians are still ill-informed about the benefits of OAT and how to collaborate with focused DSM professionals. The time must come for physicians to recognize the use of OAT for their PAP-intolerant and mild/moderate patients as the first line of therapy. The onus is on every one of us to help inform, educate, and guide them to this truism. It’s good for them, for you, for the healthcare system, and most important – for the patients.

3. Reimbursement Expectations

The national average for OAT insurance reimbursement hovers around $2,300. I want to stress this is a national average and not specific to any region, state, or health plan. Many practices I speak with begin their DSM journey with the preconceived notion that they will collect at least $3,500 on every case. Why are they anchored to this misinformation? It’s an incorrect number that’s been bandied about by unknowing commercial vendors and others for some time. Whether it is done intentionally as a sales ploy or unintentionally despite supporting data, this over-promising leads to disappointment and frustration. Instead of providers doing cartwheels because they successfully treated a patient and received payment north of $2,500, they are disappointed and jilted. They were “sold” one thing but “bought” another. Cognitive dissonance rears its ugly head. I’m going to say this plainly – The #1 reason you should step into DSM is to help patients get the treatment they need. If you focus on that, the revenue will follow. I promise.

4. Operations

Dental Sleep Medicine isn’t general dentistry. Protocols are different. A new workflow has to be implemented, but it has to be efficient and compliant with medico-legal and payor guidelines. How are you going to properly screen patients, correctly document treatment, and ensure maximum reimbursement? How are you going to do this when you have a hygiene check in op 3? This can seem daunting, particularly if you’ve been assured by someone selling a product or service that it’d be a walk in the park. Dental practice acts, laws, regulations, and Medicare and private insurance policies constantly change. How do you know if your patient’s plan allows for home sleep testing or if your state dental board permits you to order one?

It can take quite a long time to develop that rapport, generate successful shared patient outcomes, and foster sense of mutual trust that is essential for these referral relationships. There is one noteworthy recent change that has at least a tangential effect on each of these four issues, and it’s a favorable shift for the DSM field. It makes implementing DSM and increasing cases easier than ever before. There is a path through this minefield of uncertainty. It’s called telemedicine. Creating strong relationships with local physicians is always the goal, and telemedicine is a desirable solution for many situations.

Telemedicine opens doors to connect dental sleep medicine patients, sleep physicians, and dentists via virtual visits. Telemedicine is like the introduction of the iPhone. It will change the way DSM is practiced in a major way. Dentists now have the ability to connect with national sleep physicians to mutually work on driving more care to dental patients while staying 100% compliant. This game-changer is applicable for private insurance patients, and it will also work with Medicare patients, now that Medicare has modified their rules around telemedicine and face to face visits. A streamlined. consistent workflow with each and every patient regardless of the payer is now possible which positively addresses each of the hurdles I detailed. You still have to have an open mind, determination, and the right people and organizations around you. You can do this. Your patients need you.