Time to Go In-network with Medical Insurance?



by Randy Curran and Kyle Curran

As a dentist treating Obstructive Sleep Apnea, is it in your best interest to contract and become in-network with medical insurance payors? This is a common question for providers across the full spectrum of experience levels; from those new to dental sleep to expert-level practitioners that are solidly established in the industry. This inquiry arises now more than ever, as a growing volume of providers are recognizing an industry-wide shift. No longer an emerging treatment modality, Oral Appliance Therapy (OAT) is gaining traction among dentists, oral surgeons, and even ENT providers. OAT has reached a pivotal point in its life cycle. The influx of dentists who are beginning to treat sleep coupled with the litany of research demonstrating OAT’s efficacy, has resulted in a rising number of contracts insurance payors will give dental sleep medicine providers. These contracts typically offer rates ranging from $1,800 – $2,100. The question is, should you take advantage of this or remain out-of-network?

Undoubtedly, you should closely analyze the pros and cons of in/out-of-network options. For many years, the downside of contracting with medical insurance far outweighed the upside. Until recently, large out-of-network allowed amounts and easily obtainable gap exceptions have offset the time and effort necessary for in-network contracting. A shift is occurring though, and you need to know about it.

Contracting with medical insurance can result in less time dedicated to obtaining approvals, increased accuracy regarding patient out of pocket quotes, faster processing times for claims, consistent reimbursement across all billed codes, and better relationships with referring physicians. One of the most challenging aspects as an out-of-network provider is contending with the unpredictability of the allowed amounts. This variability can lead to a highly volatile, labor-intensive process to approximate the patient’s out of pocket cost. A gap exception denial can potentially render the initial quote useless and increase the patient’s cost. This undesirable cascade of events frequently results in the patient declining needed treatment.
For an in-network provider, that guessing game ceases to exist. In-network providers have a predetermined amount they know the payor will allow for the appliance. Once the patient’s specific benefits have been verified, you can confidently quote patients their out of pocket cost. This simplifies the process for both the practice and the patient and increases patient acceptance for OAT.

Along with better rates of acceptance, becoming an in-network provider should also reduce the time spent obtaining approvals and processing claims. As an out-of-network provider, there are usually two approvals that must be obtained prior to treatment: a gap exception and a prior authorization. Both approvals require comparable amounts of time for processing, but a gap exception is more prone to denial. These denials aren’t just caused by the growing number of in-network providers who treat sleep with OAT although that is a common reason. When a prior authorization is strictly based on medical necessity, a gap exception is conducted by a sole reviewer which increases the likelihood of an incorrect denial. These incorrect denials have the potential to delay treatment by up to 90 days. Gap exceptions can also cause delays in the claim process, as it isn’t uncommon for a payor to incorrectly process a claim as out-of-network, when a gap exception is on file. By eliminating the need for gap exceptions, providers should find that it requires less time to move patients into treatment and payment processing is expedited.

There are many benefits to being in-network, but the authors do not wish to create a false narrative by giving the impression that unicorns will be frolicking with leprechauns in your practice while your team sings ditties from The Sound of Music. The obstacles of contracting may include: a lengthy credentialing and negotiating process, lower contracted fee schedules than what you may be accustomed to, and a vital emphasis on compliance with contractual requirements. Many practices decide not to contract with medical insurance because of at least one of these reasons. Unfortunately, the process to contract with a medical insurance as a dentist is neither simple nor easy, and it can take as long as a year to complete. There isn’t a magic pathway or secret handshake to bypass the paperwork, phone calls, and emails that are necessary to secure a fair contract. However, once through the initial contracting process, the insurance will be more apt to offer you a new contract every cycle. The process is heavily front-end loaded, but once complete you should be set for the lifetime of your practice.

Though the current “Wild West” style of billing in the Dental Sleep profession has been somewhat successful to date, a dramatic shift is likely on the horizon. As awareness builds across the country about the importance of quality healthy sleep, more non-dentist providers will begin proffering OAT therapy. We will likely see a sizable increase in the number of oral surgeons and ENTs opting to bring dentists into their practices for the sole purpose of delivering oral appliances. Many of these providers already possess medical insurance contracts, so they may have an advantage over your practice.

Providers should weigh the potential risks and rewards of in-network and out-of-network statuses. Discuss the options with peers, billing companies, and professional organizations that have experience with each status type. Investigate their allowed amounts, the credentialing processes, case acceptance rates, time allotment, and then make the determination that is best for you, your patients, and your practice.

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