#AskT-Bone – Ep28 – Workflow for Sleep Apnea Medical Billing


What’s up what’s up? T-Bone here!

I’m in a good mood today!

And we’re going to do another #AskT-Bone on the T-bone speaks podcast!


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So today we have a question submitted by Maxwell:

Good evening Tarun! It’s been great getting to know you a little bit about you through your podcast as well as through your guests post and some of the additional podcast you are guest on. Through your podcast and its discussion regarding sleep apnea medical billing, I was inspired to come out to Raleigh and visit you in your practice and workshops. I’m slated to attend the sleep apnea course on August, as well as the medical billing course in October. However I have recently had a rapid influx of patients inquiring about sleep apnea and questing appliances be fabricated. I am excited to help these patients with their apnea, but I am not quite sure about how to handle the billing at this point. Any suggestions on how to handle a billing and setting my fees so I can get out to see you August.


Number one, Maxwell thank you so much for your support and your trust in me that you would give up your time and your money to come visit me twice in August and October. I will do my absolute best to make sure that we deliver value and knowledge and strategies to make this stuff work in your practice. So let’s talk about sleep apnea medical billing. This probably one of the pros areas in our practices, sleep apnea. Sleep apnea specifically is obstructive sleep apnea and what we do know about obstructive sleep apnea is that Dental Appliances specifically a mandibular advancement device can be used to help sleep apnea breathe better at night by holding the jaw forward and the analogy I like to use with my patients is: “Is just like CPR. One of the things we talked in CPR is to open the airway is by trusting the chin forward. And that’s what a mandibular advancement device does. It help with snoring and with breathing and there is a significant amount of attention being given to sleep apnea in the medical world, and patients are becoming more and more aware of it. In fact we know that sleep apnea is almost as probable as diabetes and there is so much attention given to diabetes, and sleep apnea has wide-ranging effects in your overall health.

Now the great news about sleep apnea is that medical insurance can and will pay for sleep apnea appliances. Now of course with any insurance there are deductibles, plan Provisions, all of those things that play a role into it.

So, today what I’d like to do is talk to you about how do you get medical insurance to pay for sleep apnea appliances.

So step one: First and foremost, please understand that medical insurance pays for medical diagnosis and medical conditions, and that means that your patient must have been officially diagnosed with sleep apnea. And that can only be done by a physician. So first and foremost you have to have as a physician’s diagnosis that is always accompanied with a sleep study. that sleep study can be the in lab PSG or HST home sleep test that can be administered at home.

So, once you have that in place, that is not enough. Because insurance companies want to make it difficult for you to get paid, so first and foremost we do an eligibility check. What does eligibility check? What we’re looking for is where we at in terms of deductibles and co-pays and is the easier 486 for sleep apnea appliance code, a covered procedure under that plan. Now once we have our eligibility check, we can get an idea of where our patient will stand financially, we assume that they will have a diagnosis. Now once we have that in place now we can get an idea of what the cost is going to be to the patient.

Now once a patient is choosing to move forward, before we actually move forward we will do, now and this is a must, absolute must, You must do a pre authorization for the sleep appliance. And that is a matter of picking up the phone calling the insurance carrier and doing a pre-authorization/pre-certification for the sleep apnea appliance and they will ask you for some letter of medical necessity, a copy of the sleep study and a copy of the physician’s prescription for the oral appliance and in many cases maybe a CPAP intolerance affidavit.

So those are some of the things that you have to have.


Now once you have this pre-authorization, from there you pretty much go. At that point it’s a matter of submitting the claim on the CMS 1500 claim form or electronically, I prefer electronically, you’ll need to provide the MD referring MD position you’ll need to provide your pre-authorization number, you need to provide all those details on that claim to provide payment. You will submit it and you can only submit it after the appliance has been delivered. So you have to wait to bill once the appliance has been delivered. And then once your appliance is been delivered you fire off your claim and then you will get your reimbursement.

And of course when you deal with any insurance nothing goes quite that easy. So there will be some times where they will deny it the will be sometimes where they ask for additional information, there will be times where they just delayed payment. So that’s where you has to be great.

Now in terms of setting fees, I think is all about your business model.

Here is what I know: Good appliances cost laboratory wise in the five to six hundred dollars to be fabricated. So typically, what I recommend for people is that I believe a good Appliance fee is in the $2500 to $3,500 ballpark. Now, if you’re doing TM combination TMD therapy, you’re doing lots of other things, then maybe your fee can be more. Now they’re also globally some other things that go along with sleep apnea therapy. In our office we do a CBCT, we do a pre HST, we do appliance therapy, we do a post CBCT, we do a post HST and all these things get wrapped up into our fee. All these things get billed out to medical insurance. So, Hopefully I have help answer your questions, so again I encourage you guys to consider attending our sleep apnea Workshop. The August course is sold out unfortunately, we have another one scheduled for November, and if you text TBONESPEAKS to 44222 you will get all my information, I promised you that. So what is unique about our sleep apnea Workshop is we focus on the workflow. We cover some fundamentals of sleep apnea, we go under the impression that you know what sleep apnea is, you know the importance of it, and you are here to learn how to do it, why to do it, how to get your patients to accept it and how to get paid for these appliances. So, we do not spend so much time on the science, we spend the minimum amount on science, and then we dive right into the workflow, we Hands On bite, the Hands-On impression, for my 3D uses we hands on CBCT, we hands on CEREC, we make sure that you know exactly how to do this. And that is our focus and this workshop. So, I encourage those of you listening to consider attending the workshop, we would love to have you, and some of our most popular workshops in their help, in our practice right here in Raleigh, North Carolina, and I look forward to seeing you. And there are always fun when I’m involved. So thank you very much, and Maxwell thank you for coming to our seminars and I look forward to it, and thank you for the question!


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