Insurance billing for oral orthotics

Provider

 

How can a patient maximize insurance coverage?

  1. Ask the members service representative if the policy allows: “Network Gap Exception” or “Network Insufficiency”. These terms mean that, even though the insurance contract states that a patient must see in in-network (contracted with the insurance company) provider to obtain maximum coverage, if the insurance company does not have a provider contracted to them, or “in-net”, who is trained to do oral orthotics, then the insurance company must pay any provider at the higher in net-work rates. Some policies, often HMOs, will not allow “Gap Exception”.
  2. Some state insurance laws preempt insurance company policy and mandate “Gap Exception”. The state office on insurance may be of some assistance.
  3. Be aware that most medical insurance companies do not know what an oral orthotic is. Some policies state that there is no coverage for “orthotic devices”. The representative will then say that oral orthotics are not a covered service. When these policies were written, this statement referred to foot orthotics (from a podiatrist), artificial limbs and other, external detachable mechanisms. It is important that you ask to receive a copy of the Medical Policy for obstructive sleep apnea. If that portion of the contract says that ‘oral orthotics’, specifically, are not covered, then there will be no coverage from the medical insurer. If there is no mention of oral orthotics under the medical policy guidelines for the treatment of obstructive sleep apnea, the patient can make an argument that the policy does not really exclude coverage. The patient should ask again if the code S8360 is a covered service.

Note: The DME provider, Northwoods, for General Motors and other auto makers claims that oral orthotics are not a covered service under the employee’s contract. They refuse to furnish providers and contracted members with a copy of the “Medical Policy Guidelines” for treatment of obstructive sleep apnea and will furnish no written proof that their denial of coverage is actually written in the contract. Northwoods claims they are not bound by state law which says that insurance companies have to provide members with written policy statements when requested. They say that under “ERISA” laws (federal guidelines) they do not have to provide this information. A patient insured through a policy with the automakers may wish to go to their human resources representative or union representative and verify that Northlands has the legal right to do this.

What about the initial evaluation by the dentist?

In my office, I attempt to pre-certify all new patients if I have the correct information. I require the patient’s: address, date of birth, a legible copy of both sides of the medical insurance card with all appropriate telephone numbers. I call the Precertification number and ask how I can apply for authorization to see the patient for an evaluation and receive payment at in-network (higher) rates. Often the insurance company will ask for copies of the sleep studies (polysomnograms) and a letter of ‘medical necessity’ from the referring physician. They also want a letter from my office explaining the billing codes I intend to use, what the fees are for each code, and expected dates of service. Some insurance companies allow these requests to be faxed to them, some require that the documentation be mailed in (it is then, often ‘lost’ at the insurance company), others may be more liberal and grant Precertification over the phone.

Denist1

Dentists play an important role in the team approach to the treatment of obstructive sleep apnea.

Physicians, dentists, psychologists, and respiratory therapists all pool their knowledge to treat each patient appropriately and effectively.

Dentists who are specifically trained in aspects of sleep medicine and have a command of multiple appliance modalities are of great help to physicians in treating patients with sleep disordered breathing problems.

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The National Center on Sleep Disorders Research, can provide you with sleep education materials. As well as publications on heart, lung and blood research:
Two Rockledge Center, Suite 7024, 6701Rockledge Drive, MSC 7920, Betesda, MD 20892-7920
(P)301.435.0199 /
(F) 301.480.3451
www.nhlbi.nih.gov/about/ncsdr/

Information about sleep disorders may be obtained from NHLBI:
NHLBI Information Center
P. O. Box 30105, Bethesda, MD 20824-0105
(P) 301.251.1222 / (F) 301.251.122
www.nhlbi.nih.gov/