MEDICAL BILLING FOR DENTISTS
PRESENTED BY MEGAN CHEEVER, RN
What is Medical Billing?
▪ The practice of submitting claims to insurance
companies in order to receive payment for services
provided to a patient by a doctor
▪ Claims include patient information, medical
insurance information, provider information, CPT
codes (procedures performed), diagnosis codes,
authorization numbers, and medical records
▪ Starting October 1, 2015 medical insurance has
converted from ICD-9 to ICD-10 for a more detailed
way to show insurance companies what the patient
is being diagnosed with
Medicare
▪ If you are not a Medicare DME provider then you CANNOT accept
Medicare – These will be cash patients
▪ If you do accept Medicare we do not have to verify benefits.
Medicare has a $183.00 deductible and covers at 80%. The
patient will be responsible for 20% unless they have supplemental
insurance.
▪ DME providers can only bill for the oral appliance. In order to bill
for office visits you must also be a Medicare Part B provider.
Insurance Verification
• Insurance verifications give us specific details including
deductible amounts, coinsurance percentages, and out of pocket
maximums
• The insurance company can provide us with the amount that the
patient has met towards the deductible and out of pocket
maximums
• We are also able to obtain whether or not preauthorization or
predetermination is required for specific procedure codes
• Reference numbers are obtained in case we have any
discrepancies throughout the process
Insurance Verification
Gap Exceptions
• GAP exceptions allow out of network providers to be considered in network for a
specific time and a specific treatment when no in network provider can offer the same
services
• GAP is not allowed on all policies
• GAP is typically allowed for 90 days / New GAP would have to be initiated beyond that
time frame
• Claims with GAP exceptions are typically paid incorrectly and require review
• GAP may be initiated by many different ways (per policy)
• Provider / 3rd party biller
• In network provider / PCP provider
• Member initiated
Preauthorization / Predetermination
• Preauthorization and/or predetermination is required by many insurance companies for the oral appliance
• They are similar in that the insurance company is reviewing if the proposed treatment is medically necessary
• Preauthorization:
• Typically gets an authorization number that needs to be included on the claim when submitted
• Typically is valid for specific dates of service
• Requires clinical information to be submitted to insurance for review
• Does NOT guarantee payment once claim is submitted
• Typically a decision is made within 15 business days
• Predetermination:
• Does not have specific dates that treatment needs to be completed
• The "approval" letter will state that E0486 is covered by this plan
• Does not have an authorization number to include on the claim when submitted
• Does NOT guarantee payment once claim is submitted
• Requires clinical information to be submitted to insurance for review
• Typically can take up to 30 business days
**Think of these as your permission to treat....if you do not have approval....DO NOT DELIVER**
BCBS will
approve
which
appliance??
ICD-10
BCBS requires
predetermination…
except when its
through AIM…then
it is
preauthorization….
Aetna says
POS must
be home….
Premera
says
temporary
appliance…
We won’t
get paid by
Cigna for
HST…
CPT and ICD-10 Codes
CPT Codes (Procedure Codes)
ICD-10 Codes (Diagnosis Codes)
▪ E0486 – Appliance
▪ G47.33 Obstructive Sleep Apnea
▪ 99201-99204 New patient office
visit (one time only)
▪ G47.30 Sleep Apnea, unspecified
▪ 99211-99214 Follow up office
visit
▪ 70355 Pano
▪ 95800 Home Sleep Study
▪ G47.9 Sleep disorder, unspecified
▪ R06.83 Snoring
Medical Diagnosis
▪ Initial visit for a patient that
comes to you with no sleep study
▪ Unspecified Sleep Disorder
▪ Snoring
▪ Fatigue
▪ Visits for a patient that has a
sleep study, or returns with a
study and diagnosed with OSA
▪ Obstructive Sleep Apnea ONLY
HOW TO DETERMINE PATIENT COST
PATIENT WITH NO
INSURANCE / NO APNEA
PATIENT WITH NO OUT OF
NETWORK BENEFITS
CASH FEE
CASH FEE
PATIENT WITH INSURANCE
DEDUCTIBLE
HIGHER THAN
CASH FEE
CASH FEE
DEDUCTIBLE
LOWER THAN
CASH FEE
*COLLECT
DEDUCTIBLE
*FILE TO
INSURANCE
*WRITE OFF
REMAINING
BALANCE
*COLLECT
DEDUCTIBLE AND
COINSURANCE BASED
OFF YOUR CASH PRICE
*FILE TO INSURANCE
*WRITE OFF
REMAINING BALANCE
PATIENT WITH INSURANCE
Cash Fee: $2500
Insurance Fee: $6500.00
Insurance pays 60%
DEDUCTIBLE LOWER
THAN CASH FEE
Deductible $1000.00
DEDUCTIBLE HIGHER
THAN CASH FEE
Deductible $5000.00
CASH FEE
$2500.00
*COLLECT
DEDUCTIBLE
($1000.00)
*FILE TO INSURANCE
($6500.00)
*WRITE OFF
REMAINING BALANCE
*COLLECT DEDUCTIBLE ($1000.00) AND
COINSURANCE BASED OFF YOUR CASH
PRICE $2500 – $1000 = $1500 X 40% =
$600.00
Total collected $1600.00
*FILE TO INSURANCE
$6500.00
*WRITE OFF REMAINING BALANCE
The Life of a Medical Insurance Claim
Patient registration and
charge entry
Claim
Transmission
Claim submitted to a
clearinghouse
Preliminary screening
of claim
Pre-edit / Audit
Dispatch to insurance
companies
Conversion to
insurance specific
format
Preliminary screening
Claim
Adjudication
Communication of
decision
Payment or Denial and
EOB sent to provider
Follow up from office
about incorrect
payment or denials
What will 3rd Party Billers require from you?
•
•
•
•
•
•
•
•
Copy of photo ID and medical insurance card
Patient phone number and address
Affidavit of CPAP intolerance
Referral from MD / Prescription
Sleep study (within last 5 years)
Letter of Medical Necessity (when requested)
Epworth Sleepiness Scale
Mild AHI requires comorbidity
• History of stroke
• Hypertension
• Excessive daytime sleepiness
• Ischemic Heart Disease
• Insomnia
• Mood disorder
• Brain Injury
• Claustrophobia
QUESTIONS
Contact Brady Billing
▪ Phone: 844-424-5548
▪ Fax: 214-975-2722
▪ Email: [email protected]
▪ Insurance Verifications: [email protected]