Do insurance companies cover oral appliance therapy?
Generally speaking most medical insurance companies provide some level of coverage for OAT. The level of coverage and specific requirements for eligibility varies with each policy.
What are the Medical Guidelines for Oral Device Coverage?
Diagnosis with polysomnography (a sleep test) is required and must be reviewed by a physician. To limit the number of patients who qualify for an oral device, insurance companies often require the severity of the sleep apnea to be a moderate-severe level (>15 breathing events per hour). Most medical insurers are likely to cover the sleep test. These details can be provided by your sleep testing facility.
Patients with mild sleep apnea (5-15 breathing events per hour) do not automatically qualify for treatment of their sleep disordered breathing, unless they also have an additional diagnosis of hypertension, heart attack, stroke, mood alteration (depression), impaired cognition (memory loss), insomnia or excessive daytime sleepiness. Each company has guidelines as to how each of these additional diagnoses must be verified prior to approval of treatment. By submitting a “pre-determination or pre-certification” request with the insurance company, we usually get a statement approving or denying the potential services prior to their completion.
Insurance companies generally will not pay for an oral device that is to be used for the convenience of the patient. This would include a patient who uses CPAP at home but wants an oral device to use when traveling, hiking or camping. The exception to this rule is with Tricare; as active duty military personnel do not always have electricity to run their CPAP machine.
Are OAT Devices classified as dental or medical devices?
Oral devices to treat obstructive sleep apnea are considered Class 2 medical devices because they treat a recognized medical disease that can only be diagnosed by a physician; therefore, only medical insurers will pay for the cost. This presents a problem since an oral device can only be made by qualified medical provider who is knowledgeable of the oral structure. Dentists are very qualified in this area since they have extensively studied the mouth and jaw structure, however; most insurance companies have by-laws that do not allow a dentist to be in-network with that medical insurer unless the dentist is an oral surgeon.
Are Drs. Horner and Ahn in-network providers for any insurance companies?
While both dentists are in-network dental providers for BCBS of AL, Delta Dental Premier, Metlife, Southland and United Concordia, at this time, they are out of network providers for all medical insurances. As described above, it can be difficult for a dentist to gain this through insurers.
Will I be affected by going to an out-of-network provider?
If you are part of an HMO (Health Maintenance Organization) you are required to have a referral from your primary care physician prior to services rendered. Tricare Prime will also require referral. As out-of-network providers, we find that Tricare Prime generally requires patients to stay in-network for oral appliance therapy.
Sometimes an authorization is required for you to see a provider who is not contracted with your insurance company (out-of-network provider like us). This process is called “prior authorization” or “pre-authorization” and can take a few days to a few weeks to complete. Please call your insurance to find out if they require any special authorizations for visits to out-of-network providers (see next page for specific codes to inquire about)
Can I still come to see Drs. Horner and Ahn and get coverage for my treatment even though they do not participate with my insurance network?
Yes, there are usually specific provisions within most insurance plans to cover a portion of services from out-of-network providers. You will need to contact your insurance company to find out if they require any special authorization to see an “out-of-network” provider.
We recommend that you check with your insurance company to confirm your percentage of coverage for services prior to your visit. The codes are: Diagnosis: G47.33 (Obstructive sleep apnea) and CPT: 99243 (consultation) and E0486 (new, custom fitted oral appliance- this is not a rental item).
Does the office have payment options that will allow me to pay for treatment over time?
Yes, we offer financing through Care Credit and Lending Club Patient Solutions which can be structured for your specific needs. These include 6 and 12 month no-interest payment plans, as well as extended payment plans from 24 to 60 months. This usually allows enough time to receive your insurance reimbursement so you can get your maximum insurance benefit while reducing your out-of-pocket expense. For more information, please contact our staff or go online to carecredit.com or lendingclub.com/dental.
Do I need to pay for care at the time of the visit?
Yes, it is our practice to require payment at the time of service and help you get reimbursed by your insurance company according to your policy. We will help prepare the necessary insurance claim forms for you to submit to your insurance company. Once your claims are submitted to your insurance, they should reimburse you directly.
Frequently Used Insurance Terms:
Indemnity Plan:A health plan that pays a specific amount for any provider you see regardless of network status. This is basically fee-for-service.
PPO:Preferred Provider Organization. This policy allows you to see a provider you wish without the need for a referral. Some of these plans pay more for in-network providers versus out-of-network providers.
HMO:Health Maintenance Organization is an insurance that pays at a higher level if you see an in network provider and rarely allows out-of-network providers to receive authorization or reimbursement. This can vary plan to plan.
UCR:Usual Customary and Reasonable or “Allowed Amount”. By law, the medical insurance companies must pay providers a fee that is usual for a covered service. In theory, this is assumed to be the average fee charged for the service in your area paid to providers. However, each insurance company seems to have their own UCR fee schedule. As an out-of-network provider, insurance companies are not required to disclose how much their UCR or “Allowed Amount” is. If your insurer says they will pay a percentage of the fee for an oral device (maybe 80%) they will only pay 80% of their UCR, not the fee submitted. Please be aware that you are responsible for our full fee as we are not obligated to accept your insurance UCR since we are out-of-network.