by Glennine Varga, AAS, RDA, CTA
As we approach the end of 2018 three factors are clear: 1. New technology is here to stay! 2. Pediatric airway awareness has risen and 3. Same and similar is a new way of life for those of you filing Medicare claims. Ok great!
You may be thinking so what does this have to do with the way our practice integrates dental sleep medicine? These three factors may not impact you at all right now, but that’s sure to change. When looking at these three factors from a team approach, can you identify the common denominator? Let me give you a hint… insurance. Let’s take a look at these three areas and the impact they may have within your practice. Please understand there may be insurance benefits available for the three factors if certain circumstances are fulfilled. Many people and institutions are pushing for benefit allowance.
New Technology
Wearables, smart blankets, and radio frequency technology are around the corner! How about the technology of Dr. John Remmers’ MATRx plus™ (Zephyr Sleep Technologies Inc. Calgary, Canada)? This option could be ideal for patients to not only obtain an airway diagnosis but also predict effectiveness with an oral device. OH MY! If I’m a patient presented with this option, I’d go for it! Not only will I know if an oral appliance will work for me, I will also have a starting position that will allow for most optimal results. Sign me up! Depending on my insurance, there may be no benefit for this option. Do I care? I can pay the fee for this service, so, no problem. But wait – some insurance plans deny benefit for the oral appliance after MATRx plus theragnostics. This is where I’d like to know the benefit I’d be forfeiting to obtain a diagnosis. It could be $200 or $2000. Because my insurance may dictate how my diagnosis was obtained and because new technology is moving so quickly, insurance companies may not recognize new methods. In addition, some plans require a physician to order the method of diagnosis as a result of a face-to-face and the physician may not recognize these new methods. Time will catch up to technology. For now, keep your patients informed of new technology and what options are available. Keep in mind that if the patients feel the value of the service, the allowable benefit from insurance companies may not matter to your patients. Personally, I understand the thoroughness of obtaining a diagnosis, outcome predictability and optimal starting position in one night, so the value outweighs the cost for me. Whether you have this new technology or another home sleep apnea test device, this scenario will occur with patients and it’s in your best interest to find a way to navigate this conversation.
Children’s Airway
The American Dental Association (ADA) has a policy statement regarding every dental office screening for sleep disordered breathing in both children and adults. The ADA is currently working on guidelines of what this evaluation will be. Talking about children’s airway with families is practice-building and solutions to help guided growth and tongue posture are patient friendly and very successful.
Since form follows function, it makes sense to look at why a child is functioning the way he or she does. Why are the dental arches forming in a certain shape or the occlusion of the teeth aligning a certain way? Ask questions of the guardians of your little patients. Change your medical history to ask questions about observed snoring, mouth breathing or bed-wetting. During the inaugural Children’s Airway Practical Conference at the ADA’s headquarters in Chicago, IL in August 2018, Dr. Christian Guilleminault described how airway can be influenced as early as conception and during the time in the womb. There were dentists present at this conference whom have dedicated their entire practices to performing frenectomies on infants presenting with tethered oral tissues, such as tongue-tie, which prevents proper development of the maxilla, the base of nasal airway. Providing the service of early orthopedic or orthotropic therapy can be a new revenue stream for your practice while helping children in your community breathe and sleep to their fullest potential. Most dentists I’ve met over the years become involved in children’s airway because of a child of their own and, once they understand the impact this therapy makes, it becomes a passion driven by many success stories and thank you cards. The ADA is hosting their next Early Breathing Conference March 3-4, 2019, also at the ADA’s headquarters in Chicago, IL. The August event sold out.
Same and Similar
Dr. Ken Berley and Jan Palmer write about this in detail elsewhere in this issue. Federal regulations at 42 CFR 414.210(f), the Reasonable Useful Lifetime (RUL) of DME, state that the RUL of any piece of DME is to be not less than five (5) years. What does this mean for your practice?
If you’re not a Medicare DME supplier, you will continue to do what you normally should be doing: Having your Medicare beneficiary (patient) sign a Medicare private contract letting them know there is benefit with Medicare DME, but they cannot get that benefit because you are not a DME supplier. Your Medicare beneficiary (patient) has to agree to pay you knowing there is a Medicare benefit.
If you’re a Medicare DME supplier and your patient has had PAP therapy within 5 years, there will be no allowable benefit for your appliance. In this case your Medicare beneficiary (patient) should be presented with an Advanced Beneficiary Notice (ABN). This is a form your Medicare beneficiary will read and decide which option is best for them. Based on the options selected, a claim may or may not be submitted. The ABN is only to be used in the event you do not expect Medicare to allow benefit. If PAP therapy has not been attempted within the past 5 years and all the criteria of Medicare Local Coverage Determination (LCD) have been met, the ABN should not be used because you expect payment. CMS is allowing dentists to appeal by providing documentation showing that CPAP usage has been discontinued by the treating physician, that all Medicare regulations were followed to the letter, and all payments for PAP therapy have ceased. Then, and only then, Medicare will consider an appeal for MAD benefit.
This isn’t a new regulation, but Medicare’s internal systems needed to catch up to the rule in place for several years. Now that their system is communicating properly it is in our best interest to inform the patient when benefit is not allowed due to the Same and Similar rule. Everyone on the team needs to master the communication skills necessary around this complex and confusing topic.
Embrace what the future has in store for us. Use new technology to educate your patients and empower their decisions. Take a look at children’s airway therapies or whom you may be able to refer to and work with in your community. Stay on top of the latest information coming out of Medicare – it sets the stage for private insurance companies to model.
Editor’s Note: This Sleep Team Column will be dedicated to the team and provide practical tips and resourceful information. Let us know your specific issues by email to: SteveC@MedMarkMedia.com. While we can’t respond to every individual, your feedback will help us create the most useful Sleep Team Column we can.
Knowing about insurance options is important for case acceptance in a dental sleep practice! Read “Maximize Medical Insurance Benefits.”
