Author: Michael Kelley

SYDNEY, AU – SomnoMed Limited will close all Renew Sleep Solutions (RSS) operations by the end of 2018. The announcement from SomnoMed Chairman Dr. Peter Neustadt came earlier this week during the company’s annual general meeting. Neustadt also reported that CEO Derek Smith has agreed to step down, while Neil Verdal-Austin will be installed as the new CEO. The RSS closures will end a two-year “direct to patient” concept for the treatment of obstructive sleep apnea (OSA) that began with treatment centers set up across the United States. “The first RSS centre opened in December 2016 and early results of the first group of four centres seemed to confirm our original assumptions,” said Neustadt during the meeting. “The reaction to our initial advertising campaigns was good. In total we have received over 60,000 inquiries since RSS started operations. As with any new business, there were a number of issues which were considered to be solvable and not abnormal given the complexity and novelty of the business. These included initial start-up issues in our call centre, in the arrangement and timing of sleep diagnoses, in the accreditation of dentists with insurers, in finding the right media strategy and advertising content and in lifting the conversion rates.” According to Neustadt, the closures were ultimately motivated by high advertising costs and lower patient numbers than expected, primarily due to significant increases in health insurance premiums—all of which had “a devastating impact on the RSS business.” The following italicized material is a transcript that details the externals factors that led to the closure decision: 1) Significant increases in health insurance premiums have occurred in the USA since the beginning of the 2017, which led to high increases in “deductibles” (the amount of cost the patient has to pay out of his or her own pocket before the insurer starts to contribute). This has impacted on medical treatments which were considered to be non-essential (elective). Many patients delayed their decision to proceed once they realized the amount of money required to pay out of their own pocket, given the higher level of deductibles than previously. Whilst we saw this initially as a sign of a more pronounced seasonality of our medical business, it has reduced the overall demand more than we expected, dragged our conversion rate down and produced lower patient numbers than we expected. 2) In the last six months we have experienced a reduction in the average yield per patient received by RSS of around 25%, linked to the reduction or reimbursement amounts by certain insurers. The reduction in yield, high advertising cost and lower patient numbers than expected increased the losses to an unsustainable level in the last few months. The closure of some centres in September this year created some relief but not sufficient to make a fundamental difference to the economic viability of the business and its likely future funding requirements. “Whilst we believe there may be a future for a ‘Direct to Patient’ approach for the treatment of OSA, especially given the lower acceptance of COAT™ in the US compared to other countries we are operating in, it would require more time, more money and a lot of good management to turn RSS into the business we were originally expecting to have,” said Neustadt. “Further, even given time and money, there were other risk factors to consider if we decided to continue with RSS. Such risks include the possibility of more insurers reducing the level of reimbursement, further negative reactions from SOMNA’s customers, much more capital needed, as losses could possibly stretch into 2019/20, and the distraction of our group management. Each of these risks could impact on the positive prospects of SomnoMed’s core business, which offers significant growth potential in the future.” In the decision to part ways with CEO Derek Smith, Neustadt cited changed circumstances that made new leadership essential. “In appointing Mr. Verdal-Austin as SomnoMed’s new CEO, the Board selected a candidate who has worked for our company for over ten years successfully as CFO,” Neustadt said. “In addition to his CFO role, Neil also managed as executive vice president for SomnoMed’s APAC region, with our businesses in Australia, New Zealand, Singapore and South Korea for a period of four years from 2014 to the end of June this year…my priority right now is to re-focus SomnoMed back onto a safe and credible pathway, optimizing revenue growth and building group profitability.” Neustadt’s full comments can be viewed HERE   Source: Finance News Network Australia

How did David Gergen, a nationally respected dental lab technician, manage to find former National Football League (NFL) players interested in helping him spread awareness about dental sleep medicine? The short answer is they eventually found him. Prior to his current roles as CEO of the American Sleep & Breathing Academy (ASBA) and president of the Pro Player Health Alliance (PPHA), Gergen coached high school football at an elite level, eventually winning a state and national championship. The achievement attracted attention from NFL officials who asked him to run a coaching clinic with former NFL players. Players such as Brian Davis, an all pro defensive back with the Washington Redskins and the Minnesota Vikings, and offensive lineman Derek Kennard, who played with the Dallas Cowboys and Arizona Cardinals, received instruction from Gergen on how to coach the fundamentals for youth players. A bond of friendship developed between Gergen and Kennard, so much so that Gergen eventually confronted Kennard who frequently had low energy during the coaching clinic. “Derek had big raccoon circles under his eyes and he would lean and close his eyes during breaks,” Gergen says. “I said to him, ‘Derek, either you have the worst sleep apnea that I have seen in a long time, or you’ve been out drinking for about a hundred days straight.’” Alcohol was not the problem, and the 6-foot 3-inch, 300-pound lineman explained that he simply could not wear a CPAP mask. As it turned out, Kennard had never heard about oral appliances as a treatment for CPAP. What happened next would help hundreds of retired NFL players, while also helping to spread sleep apnea awareness among Americans who take notice when their football heroes speak about medical problems. The ASBA got the remarkable story from Gergen during a chat in late 2018. ASBA: What happened after you told Derek Kennard about oral appliances? David Gergen: I took him to a friend’s dental office, and we took his bite impressions and I got him a rush from my lab on the oral appliance. We placed a Herbst device and I left on vacation. ASBA: What was Kennard’s reaction? Gergen: After a couple of days, I got a call from Derek at about 2:30 a.m. and I figured the oral appliance was not working. I decided to answer the phone and DK said, ‘David, my brother died tonight from sleep apnea.’ He died with a CPAP machine next to his bed. Derek said, ‘We have to do something because so many of my brothers from around the NFL are suffering from this. Without you telling me about this treatment, I would not have known.’ That was the first time Derek had the idea to launch the Pro Player Health Alliance (PPHA), and we did. After Derek and I met and talked, we reached out to Mike Haynes [member of the Super Bowl Champion Los Angeles Raiders and an inductee to the Pro Football Hall of Fame] and he also said, ‘Let’s do it.’ ASBA: What happened next? Gergen: We spoke with the Living Heart Foundation, which does NFL screenings. Dr. Roberts who heads the foundation was thrilled and said, ‘Yes!’ We gave him my background and he also said, ‘Let’s do it.’ ASBA: Where did the money come for this endeavor? Gergen: There was no money coming in for us, and the NFLPA [NFL Players’ Association] did not even know about us, so I had to fund it all. It’s a worthy cause and I was glad to pay for it. We went to a couple of screenings with Dr. Roberts and things were going well. We were finding out that many of these guys had sleep apnea. We were telling them they had it, but we were not yet doing anything to help them, because the screenings were not set up for treatment. I said, ‘This is great we’re telling them, but we’re not yet doing anything to help them.’ ASBA: How did you manage to get the NFLPA interested? Gergen: Mike Haynes eventually said, ‘David, we must go talk with the NFLPA and the NFL Alumni, and maybe we can get some funding.’ We met with the alumni and we talked with Bart Oates [10-year pro who won two super bowls as a center] about doing this. He thought it was great, but at the time could not get the funding. We reached out to the NFLPA and Andre Collins [an outside linebacker who played ten seasons in the NFL and is currently the director of Retired Players for the NFLPA] in particular. After meeting with Andre, he said, ‘Let’s take it slow and see how it works out, and we’ll go from there.’ It went well for a while, and then I got a call from Dr. Roberts and he basically said, ‘We really can’t do this because we don’t have the funding, and the medical doctors did not like the fact that we were treating NFL guys with oral appliances. The MDs strongly recommended a course of CPAP instead. ASBA: What was the result of this negativity? Gergen: The program stalled, but then my laboratory got a call from the NFL Commissioner’s office, and they said, ‘We have a player who has been in a rough situation. One of the teams did not treat him properly and we need you to step in and help him.’ He was an all pro with the Bears and we tested him at the Super Bowl and he came back with an AHI score of 50. Thirty were obstructive and 20 were central. He looked terrible too, and had not been getting any sleep. Initially we put him on auto PAP and then we got a call from the physician in Florida where he lived, and he wanted to also do an oral appliance to keep his pressure down. We treated him with combination therapy. The player actually called and thanked me for the treatment. ASBA: What was happening (if anything) with the NFLPA? Gergen: Well, I am persistent, and right about that time, we got a call back from Andre Collins, and he heard about what we did [with the Bears player] and he wanted to resuscitate the program. From that day forward, we have been working with the NFLPA and our program continues to grow. ASBA: Why has it grown? Gergen: It is exciting to work with the NFL and its retired players. Football is the number one game in America, and it adds that level of fun. And we have such a high success rate with the former players that Andre Collins at the NFLPA is very pleased with the sleep apnea program and how it has flourished. And that is where we are at today. ASBA: How many retired players have you tested and treated? Gergen: We have tested and treated about 1,200 NFL guys. We have a recent screening in Dallas on Nov 17 at Baylor Hospital. Dr. Harry Sugg and Dr. Ed Hobbes were the participating dentists, and both are diplomates of the ASBA.     Don’t Miss the 2019 Conference ASBA Annual Sleep and Wellness Conference 2019 April 12, 2019 @ 9:00 am – April 13, 2019 @ 5:00 pm Pointe Hilton Squaw Peak, 7677 N 16th St Phoenix, AZ 85020 United States + Google Map The 6th Annual Sleep and Wellness Conference is the 2nd Largest Dental Sleep Medicine meeting in the U.S. With over 600 attendees expected for the 2019 meeting, its rapid growth is due to a commitment to growing the practice management side of dental sleep medicine for its members and the industry. Visit Sleep-Conference.com to learn more.

The American Sleep and Breathing Academy has lost one of its founding members. Dr. Elliott Joel Alpher passed away suddenly at his home on Saturday, November 10, 2018. Dr. Alpher, DDS, DACP served the ASBA in many capacities, most recently as Vice President of the organization. In 2016, he was the first ASBA member elected into the ASBA Hall of Fame. Dr. Alpher was a graduate of The Georgetown University Dental School and dedicated his life to providing lasting relief to patients with sleep disorders and jaw pain. Elliott was a loving and devoted husband and father. He adored his three grandchildren and loved spending time with his family. He will be greatly missed by all who loved and knew him. To leave a message on the tribute wall Click Here **************** We lost a GIANT You remember him as Dr. Elliot Alpher.  I remember him as my many decades long best friend, who always emphatically stated that we were joined at the hip and were true brothers. Elliot was joyful and passionately hard-working last week. He left us suddenly. A void has hit us.  A magnificent sandcastle on a beach can be washed away with time.  Elliot used sand to polish thousands of OSA oral appliances and TMD orthotics. For those of us who know him, he will forever remain magnificent no matter the force of tides. Dr. Alpher served the sleep/TMD dental and medical community with extreme passion, knowledge and that rare teach-ability that oozed and flowed perfectly as he taught thousands of professionals continually over decades. His passing was quick. His life was long and worthy. He fulfilled the true mission of life. We are better off because of him. Elliot and I were honored to represent dentistry for consecutive years explaining OSA to Senators, The Department of Transportation, Federal Motor Carrier Association and to staff and members of Congress in Washington, D.C.  During the last 30 years, he and I were on The Board of Directors of the International College of Craniomandibular Orthopedics, The American Academy of Craniofacial Pain and the last 5 years, the American Sleep and Breathing Academy. The ASBA has bestowed the lifetime achievement award on him and elected him as current Vice President. We spoke often since cell phones were invented, 2-3 times per week on the way to and from work.  The day of his demise, we spoke of heading a research project on OSA and dentistry nearing its completion.  The progress he strived to enhance for dentistry has been planted by multiple seeds that his passion proclaimed.  They will continue to proceed.  That is his legacy. His strength, humor and stubborn push for dental progress may slip apart from our now non-joined hips, but he will never leave my heart. Richard E. Klein D.D.S. Warren, MI

Well before the American Dental Association (ADA) made their strong recommendation for oral appliances last year, dental sleep medicine showed no signs of stopping its steady climb into the medical mainstream. For the founders of imagn Solutions, Orem, Utah, accommodating growth and helping more dentists succeed is a matter of the right dental sleep software, medical billing software, coaching, and education. Crystal May, co-founder and COO, has seen the leaner days when dentists had fewer options. “I’ve been heavily involved in dental sleep medicine for over 10 years and medical billing for more than 17 years. At that time, there was nothing available.  There was no consistency in protocols and rules, medical billing was unknown; we had to find the codes, do the research, and often when we called insurance companies they would refuse to talk to us, we were a dental office. Honestly, they didn’t know what we were talking about, they could not even find the codes.” Fortunately, 2018 and beyond is a “totally different world.” Awareness is high among members of the public and clinicians, but many dentists are still finding it difficult to jump on the bandwagon. The American Sleep and Breathing Academy (ASBA) sat down with Crystal May to discuss the opportunities for dentists who are willing to commit to the burgeoning field of dental sleep medicine. ASBA: How do you fit into the industry? May: imagn Solutions focuses on solutions for sleep and medical billing, that were built specifically for dentistry.  Our complete solution for dental sleep medicine includes software, medical billing services, coaching, education, and much more.  Our software and medical billing platform streamlines the process to overcome the most common obstacles offices face. Whether it is an office new to dental sleep medicine or experienced in dental sleep medicine, we can improve their process.  Our software is cloud-based, so it can be used with any practice management software. We are the solution for general dentistry practices, we are built for them. We have also worked for diligently to get an advanced connection in Dentrix. This connection eliminates the need to duplicate enter patient information, treatment plans and clinical notes, to name only a few.  With an imagn Sleep tab in the patient Dentrix chart, the workflow in seamless. ASBA: How does diplomat status fit into a dentist’s preparation for this field? May: Diplomat status is not tied to insurance payment. However, the single biggest differentiation between success and failure in dental sleep medicine is how trained and committed the dentist is. If you have gone through and received diplomat status, it means you have put the effort in, you have studied, you have taken the tests, and you have passed. The likelihood of you succeeding is far greater than others. We think diplomat status has real value for dentists. ASBA: Are the insurance companies on board these days with dental sleep medicine? May: Dental sleep medicine is one of the most common billable dental services. About 85% of insurance payers have policies that pay for oral appliances when the patient has a diagnosis of OSA.  The process is tried and true and as long as you follow the protocols and rules, patients can now have benefits for the care they really need. When I surveyed a large group of MD’s, they all said that a dentists ability to successfully bill medical insurance was a requirement for them to refer.  This is a huge part of bridging the gap between medicine and dentistry. ASBA: What was the situation a decade ago? May: It was exponentially different 10 years ago. Back then, from an awareness perspective, most of the sleep specialists I worked with had never worked with a dentist trained in dental sleep medicine and few patients had coverage for OAT. Sleep specialists were not following their own organization’s recommendations to refer for certain cases.  CPAP was the standard of care as far as the payers were concerned no matter the severity of the diagnosis. ASBA: What’s the situation now? May: Now it’s quite the opposite. There are hundreds of sleep specialists who now recommend oral appliances as the first line of treatment for appropriate cases.  And for the first time in my experience, patients are coming in educated and asking for their dentist to help. Home sleep testing is readily available and treatment outcomes are much predictable.  Medical billing has become more manageable, and a majority of policies allow for oral appliances. ASBA: What are some of the factors that made that possible? May: These improvements are a product of the industry showing a significant improvement in the ability to handle patients and follow protocols.  More comfortable appliances, consistent outcomes in medical billing and the advancement in technology, like our software, 3D scanning and access to home sleep testing are all key components.  The organizations created for this division of dentistry have been critical in these advancements, and I believe we are just at the tip of the iceberg. The ADA made their strong recommendation for dentists to screen for sleep related breathing disorders.  This will have a big impact on new dentists getting involved, and a company like imagn Solutions will be necessary for them to be successful. ASBA: What services do you offer to dentists? May: As mentioned earlier, we have our imagn Sleep software, with an integrated medical billing portal.  We also offer medical billing software and service for all dental services, such as surgery, perio treatment, diagnostics, implant procedures, grafting, any procedures related to a trauma, and more.  We have onsite coaching and consulting. We are accredited educators, and teach both doctors and teams throughout the country on both sleep and medical billing. As I speak for other organizations and universities, I focus on the team training aspect, really helping with the practical implementation.  The now what, that is often the million dollar question after a clinical course. Dentists hire my company to come on site and to help them improve the dental sleep medicine process in their everyday protocol. We pride ourselves in our screen-every-patient protocol. It’s the idea that every dentist in the country is being asked to participate in dental sleep medicine, whether they want to actively treat OSA or just screen and refer, it’s up to them, but it’s not an option for dentists to stay out of this space. And honestly, once they see the life changing effects sleep treatment can have on their patients, I don’t know why they wouldn’t want to. ASBA: For dentists who do general dentistry, how difficult is it to get involved in dental sleep medicine? May: Dental sleep medicine can be a challenge to incorporate. Adding something new to an already busy dental practice can be overwhelming, for both the doctor and the team.  A clear understanding of procedures and protocols, team training and software are a must! We have created the digital workflow so that dentists can integrate this life-saving protocol of screening and treating sleep-related breathing disorders and still be efficient in their practice. ASBA: What are the typical hurdles for dentists? May: One of the problems is team training. It starts with paperwork and having comprehensive conversations. In a lot of offices, the dentists will take programs and residencies and be diplomats, but their staff has no clue about the science behind sleep and the passion they need for this. That’s an obstacle. Dental sleep medicine gets a bad rap because many dentists have tried and failed because they did not start with the right tools. They were surprised when implementing sleep did not work well. Many educators in this space have not been in the providers’ shoes. A lot of educators don’t work in small towns with high turnover and poor patients, or they don’t work in super busy offices.  These dentists already have obligations and obstacles before they ever even try to incorporate sleep. We try to work within the existing dental system and not disrupt the practice. Even for some of my most successful customers who are changing lives and very successful, it took them six months to a year to fully incorporate sleep into their protocol. You must have a realistic expectation. This is not going to be like selling electric toothbrushes. ASBA: What about medical billing? May: Medical billing is another big obstacle. There are a lot of rules and regulations. In 2019, most medical payers will no longer accept any paper claims. If you don’t have a software that can connect to a clearing house, you will get rejections on paper claims. That is already happening. They literally mail the claim back to you.  You must have electronic claims submission.   Not to mention the liability. Not to scare anyone away, but be careful and diligent in the rules and documentation. Medical Billing is black and white, and we pride ourselves in only teaching the RIGHT way to do things. ASBA:  What would you say to those that have not started to implement dental sleep medicine in their practices? May:  Now is the time to get started. You can get the support you need.  You can separate your practice and be a hero to your patients. Imagine how your patient will feel when you have medical insurance cover some of their expense.  When you identify a condition that basically no one else will find, you have a fan. Dentistry, in my opinion, has the potential to change health as much as any healthcare provider. About Crystal May Crystal May – Co-Founder and COO of imagn Solutions, a company dedicated to helping dental practices be successful in dental sleep medicine through education, consulting, team training, medical billing and more. With over 17 years of medical billing experience, 10 with an emphasis on sleep treatment, she is considered a leading educator on the topic. Having owned and managed multiple dental practices, she has mastered the process of implementation, overcoming the obstacles associated with dental sleep and shares that knowledge with dental practices throughout the country.  

In writing this article, I have partnered with my dear friend, Jan Palmer.  Hopefully, together, we can shed some light on the complex subject of Medicare “same or similar” regulations, which have recently resulted in the routine denial of Medicare OAT claims. Federal regulations on the Reasonable and Useful Lifetime (RUL) of a piece of Durable Medical Equipment is a complex matter and readers are, hereby, forewarned that this is the most complicated article that I have attempted on the subject of Medicare Billing.  WARNING, this will be boring! With that said, I cannot thank Jan enough for keeping me straight and for her tireless efforts to advance the field Dental Sleep Medicine and Medical Billing. Ken Berley, DDS, JD, DABDSM History of Medicare Durable Medical Equipment (DME) for Oral Appliance Therapy Dental Sleep Medicine (DSM) took a giant leap forward in 2011, when the Centers for Medicare and Medicaid Services (CMS) opened the door for dentists to participate in Medicare, by offering Oral Appliance Therapy (OAT) for the treatment of Obstructive Sleep Apnea (OSA).  At the urging of the American Academy of Sleep Medicine (AASM), OAT was classified as DME, which is a subcategory of Medicare Part B. As a result, when dentists provide OAT for Medicare patients, they are functioning as a medical equipment supplier. While we do not issue canes or wheelchairs, dentists, providing OAT, are not view by Medicare as a healthcare provider. The decision to place OAT within DME ensured that Sleep Physicians would maintain oversight of Oral Appliance therapy and remain in control of patient care.  This is due to the fact that all DME requires a physician’s prescription before the equipment can be dispensed. Therefore, no dentist can legally fabricate an oral appliance for the treatment of OSA, without a prescription from a supervising prescribing physician. As a consolation prize for dentists, Medicare did included verbiage which limited the fabrication of an oral appliance (OA) to a licensed dentist.  Therefore, any physicians that are fabricating oral appliances for Medicare patients are in direct violation of the currents CMS regulations. Therefore, for a beneficiary to qualify for OAT benefits, a sleep physician, must diagnose the patient’s OSA, and the supervising physician must write a prescription for OAT which must then be filled (provided) by a licensed dentist.  The diagnosing sleep physician’s notes must reflect the OSA diagnosis. Dentists get their authority to treat an OSA patients from the diagnosing and prescribing physicians and must rely on the notes of these practitioners to document the appropriateness and medical necessity of OAT for reimbursement. Regulations Outlined The local coverage determination (LCD) L33611 and related policy article A52512 outlines what is necessary for OAT to be a covered service. Some of the more commonly misunderstood criteria are: The beneficiary must have a face-to-face examination with a physician prior to the diagnostic PSG/HSAT, a copy of this summary should be readily available should Medicare request the notes (good practice to obtain prior to treatment), and The detailed written order must be issued (signed and dated) by the prescribing physician and the MAD must be delivered, within the 6-month period from the date of the pre-diagnostic face to face examination visit to appliance delivery, and   The diagnosis of any SDB must be made by a sleep physician and any diagnostic testing for SDB must ordered by a physician.  The LCD specifies a dentist may not order the diagnostic test, it is the responsibility of the supervising physician to determine the appropriate treatment based on the severity of the beneficiary’s SDB, and   It is acceptable if the physician that ordered the diagnostic test is not the physician that signs the detailed written order (DWO) for OAT. An example of this would be: Beneficiary sees primary care physician, discussed sleep related issues, PCP orders a PSG/HSAT which is interpreted by a board-certified sleep MD. The beneficiary may see the PCP or other physician qualified to treat SDB after an OSA diagnosis who then determines the appropriate therapy for the treatment of the patient’s OSA.  It should be noted that a post diagnosis appointment with a physician is not mandatory under the LCD. The OA must be issued (provided) by a licensed dentist, as a medical supplier, this makes it possible for dental offices to enroll as DME suppliers. (Physicians cannot legally provide OAT and bill Medicare).  OAT is a covered Medicare benefit if appropriate for the patient and medically necessary. Once an OSA diagnosis is made by a physician, the treating dentist is provided a signed DWO (prescription) for OAT. The supplier/dentist is then required to provide a Medicare approved appliance that has been fabricated by a Medicare approved lab. The information on which labs and appliances are Medicare approved, can be found on the Pricing, Data Analysis and Coding (PDAC) website www.dmepdac.com . Readers should refer to Local Coverage Determination (LCD) L33611 and the related oral appliance policy articles (A52512 and A55426) for documentation requirements for OAT for treatment of OSA. A thorough understanding of the LCD and related articles is mandatory for any dentist filing Medicare.  Therefore, keep these articles available as a reference! Reasonable and Useful Lifetime for DME Under Federal regulations at 42 CFR 414.210(f), the Reasonable Useful Lifetime (RUL) of DME, states that the RUL of any piece of DME is to be not less than five (5) years.  Under the RUL, Medicare will not benefit multiple pieces of DME that are utilized to treat the same condition. For example, Medicare would likely refuse benefits for a motorized battery powered wheelchair and a standard wheel chair.   The same or similar provision is an attempt to prevent the payment of duplicate therapy (i.e. you only get one wheelchair). Therefore, if Medicare has paid for a piece of DME for the treatment of OSA, any new claim that you submit within 5 years for the treatment of OSA will be denied.  A beneficiary cannot have two pieces of DME that have been determined to be the “Same or Similar” to treat OSA. Sadly, CMS has determined that CPAP and OAT are “similar” pieces of DME use to treat OSA. Medicare will pay for the replacement of a piece of DME during the first five years of use if the item is lost (due to extenuating circumstances such as flood, hurricane and natural disasters), irreparably damaged or the beneficiary’s medical condition changes such that the current equipment no longer meets the beneficiary’s needs. Replacement due to irreparable wear during the period of reasonable useful lifetime is not covered. Since CPAP and OAT have been classified by CMS as same or similar devices, under the RUL guidelines, Medicare will only pay for one of these therapies every 5 years for the treatment of OSA. March 2018: Medicare Same or Similar Denials For the last seven years, dentists have been filing Medicare for OAT without any significant problems.  Then in March 2018, CMS updated their system in response to the increased payments for OAT. The “Same or Similar” system update was in response to some patients utilizing both CPAP and OAT, which violates CMS regulations.  Medicare’s system is now fully updated and programed to automatically deny any claim for OAT if Medicare has paid for CPAP within the last 5 years. The enforcement of the CMS “same and similar/ RUL” policy has significantly affected many DSM practices. Since the March update, the OAT Code is linked to the CPAP Code as same or similar devices for the treatment of OSA. Therefore, as of March 2018, if a Medicare beneficiary has had a CPAP for more than 90 days within the last 5 years, any claim submitted for OAT will be denied. Why is 90 days the magic number? During the initial 90 days of PAP rental, the treating physician is expected to evaluate whether CPAP is the best therapy to treat the beneficiaries OSA.  Once satisfied with compliance and efficacy of CPAP therapy, the treating physician signs a Medicare CPAP Certification. Certification is appropriate whenever the beneficiary utilized CPAP for 4 hours or more per night for a minimum of 21 out of any 30-day period within the first 90 days of CPAP usage.  If a Medicare patient has had a CPAP for more than 90 days, you can be sure that Medicare has funded the PAP therapy. Once the certification is signed and Medicare pays for the PAP therapy, any oral appliance submitted will deny due to RUL. CMS position on Same or Similar for OAT Repeated letters to the Medical Directors at CMS, have finally resulted in some concessions.  It is now the position of CMS, that if a dental practitioner can provide documentation showing that CPAP usage has been discontinued by the treating physician, that all Medicare regulations were followed to the letter, and all payments for PAP therapy have ceased, then, and only then, Medicare may will benefit OAT. Documentation Needed for Appeals? What if the patient fails PAP after 91 days of use? If the beneficiary “fails” PAP therapy after day 91, the probability of overturning a denial significantly decreases. The claim will be denied due to the RUL regulations. Treatment timeline must be well documented, and the ordering physician must now enter an order to “discontinue (DC) PAP therapy” and order OAT. If the ordering physician’s notes do not show that CPAP was discontinued, Medicare will not benefit OAT.  As a side note, these requirements are problematic from a legal standpoint, as no reasonable Sleep Medicine Professional should DC any therapy without an alternative therapy in place.  In other words, if PAP has been prescribed by a physician, it might be a breach of the standard of care to DC this therapy before a MAD has been delivered. Additionally, the beneficiary’s DME PAP supplier must discontinue billing Medicare for PAP expenses and the supplier’s notes must reflect that PAP was discontinued. The PAP supplier’s notes should be included in any denial reconsideration and show that all PAP expenses have ceased. The ordering physician’s treatment notes must document why the Medicare beneficiary failed PAP and show that a valid attempt was made to comply with therapy. The treating dentist cannot provide this documentation, it MUST come from the ordering physician. What if the patient fails CPAP before Certification? If the ordering sleep physician determines that the beneficiary has not met the requirements for PAP certification, it is extremely important that the sleep physician’s notes document that the PAP was discontinued and why it was ineffective.  A MAD fabricated and delivered prior to the certification of PAP will be paid with no denial. Therefore, it is ideal if the diagnosing physician can determine the most appropriate treatment for the beneficiaries’ SDB as soon as possible to give DSM practitioners adequate time to deliver a MAD within the first 90 days of treatment. Unfortunately, DSM providers will likely have a difficult time delivering a MAD within the first 90 days of OSA therapy if PAP is dispensed initially due to scheduling and fabrication time. Therefore, most Medicare beneficiary’s that are referred for OAT will likely have a claims history which will include a payment for PAP within the last 5 years and OAT denial is likely. You received your first denial, now what? Appeal: The first level of the appeals process requires that you submit a “redetermination”. The Medicare redetermination request form is available at https://www.cms.gov/ or on your DME jurisdictions website. When filing a redetermination, include as much documentation as you have to support overturning the denial of your claim, such as the physicians written order, (which must be dated within 6 months of the original face to face office visit pre-diagnosis), the diagnosing physician’s office notes for the face-to-face examination, a copy of the sleep test (PSG or HSAT), PAP prescription, DWO, physician’s office notes regarding PAP failure, PAP discontinuance order, the treating dentist’s clinical intake examination and delivery appointment notes and a copy of  the denial. The redetermination must include any and all supporting documentation necessary to prove medical necessity for OAT after DC of PAP. Include the PAP supplier notes if available, to show that PAP expenses are no longer being billed to Medicare. This will show that the beneficiary is not utilizing combination therapy, which would be a violation of Medicare regulations. Include the physician’s notes to explain any lapse in the continuation of care. For example: (PAP returned 12 months ago and there has been a lapse in treatment). Your dental intake examination and the order sleep physician’s notes should document how the beneficiary’s symptoms have worsened making OAT “medically necessary”. The more medical justification you provide, the better the chance of overturning the denial. The more time that the rental of PAP is over day 91, the less chance you have of a successfully outcome. What if the redetermination is denied? A Level II appeal is your next course of action which is known as a “reconsideration” of the claim. Again, the appeal must be requested in writing and the necessary form can be obtained at https://www.cms.gov/.  It is essential to include all supporting documents that you have available.  Explain why the denial of your redetermination was inappropriate. The reconsideration request will be reviewed by the qualified independent contractor (QIC) for your jurisdiction. This is the last level of the appeals process which allows you to submit supporting documentation, therefore, it is imperative to include all the information you have that can support overturning the case. Advanced Beneficiary Notification (ABN) Given, the system update and restrictions associated with the “Same or Similar” policy, it is vitally important to determine whether the Medicare same or similar restrictions will apply for any Medicare beneficiary.  If you determine that a patient’s Medicare claim for OAT will be denied under RUL, it may be advisable to have that patient execute an Advanced Beneficiary Notification (ABN) to inform the patient that their Medicare claim will likely be denied. The ABN places the beneficiary on notice that if the Medicare claim is denied, then they will be personally responsible for the charges for OAT.  If you fail to obtain a signed ABN from the patient prior to rendering the service, your practice will not be able to collect any amount due from the patient when Medicare denies your claim. Without a properly executed ABN, the providing dentist cannot charge the beneficiary for the OAT. Therefore, a signed ABN may be useful when a RUL denial is expected. A denial should be expected when a Medicare beneficiary is referred for OAT and there has been more than 91 days since the beneficiary was placed on PAP.  Participating and non-participating Medicare suppliers should execute an ABN prior to impressions when a Medicare denial is anticipated. When presented with the probability of a denied Medicare claim, the beneficiary can make an informed decision. Unfortunately, if an ABN is signed, the appropriate modifier must be used when filing to inform Medicare that an ABN has been executed.  This act ensures that your Medicare claim will be denied and makes a reversal of this denial more difficult. When submitted with the appropriate ABN modifier, Medicare is placed on notice that “the supplier feels the item will not be a covered service and the beneficiary has been informed of this fact and understands why the item will not be a covered by Medicare.”  Refer to the LCD for more information regarding correct coding for oral appliances that do not meet Medicare guidelines. If an ABN is on file and the office is instructed to submit to Medicare, when the claim is submitted correctly the resulting denial will indicate that the beneficiary is responsibility for the charges. Providers should be aware that they are then required to collect the fee that was submitted. (i.e. if you file for $6500.00, you are required to collect that amount). If the beneficiary is willing to forego filing the claim to Medicare, a cash discount may be possible.  The patient becomes a cash patient when an ABN is executed, and option B is selected on the ABN document. If option B is selected, the patient must understand why no Medicare coverage is expected and that you will not file a claim with Medicare for the OAT.   Under that scenario the patient becomes a cash pay patient and could be offered an appropriate cash discount. Extra Tip:  Most offices are unaware that some medical insurance companies, may refuse to allow you to collect from a patient, on denied claims if you are in-network.  Therefore, prudent practitioners may want to start utilizing an advanced patient notice for services that a private payer might not cover. Some payers will accept the Medicare ABN, but some have their own form.  If you are in-network with one or more medical insurance companies, you should check with those payers and see if they have an ABN-type notices for your use. What if a physician orders OAT as the first line of treatment and it is not effective? If OAT is the first line of treatment, the ordering physician is responsible for evaluating and documenting the effectiveness of the therapy.  Once the sleep physician determines that OAT is inadequate, PAP may be ordered if the beneficiary qualifies under LCD L33718. Again, a claim for PAP will automatically be denied as not reasonable and necessary when submitted.  The PAP will be classified as “same or similar treatment within the 5-year RUL”. Timing is of the essence, however, if PAP is initiated immediately after failing OAT, the denial would have the possibility of being overturned at first level appeal.  PAP will always receive preferential treatment. Why wasn’t the dental sleep medicine community Notified? Medicare jurisdictions are continually updating their systems, since there was no policy change, no notification was required. Same or similar/RUL has been in place since 2001.  This is not a new policy; the system was just updated to apply to CPAP and OAT. Conclusion: Once diagnosed with OSA, the treating physician has the option of choosing what therapy is best for that beneficiary. Commonly, sleep physicians prescribe PAP as first line therapy.  Once PAP is dispensed, there is a 90-day certification period where the beneficiary must document usage of 4 hours per night for 21 nights in any 30-day period during the first 90 days of treatment. If the beneficiary satisfies these requirements, the sleep physician will certify that the beneficiary has been successful, and Medicare will pay for the PAP.   If the beneficiary does not qualify for PAP during the 90-day certification period, Medicare will not reimburse for the PAP and the beneficiary is eligible for benefits for an OA. If your patient has utilized PAP therapy more than 90 days, your Medicare claim for OAT will be denied.  However, on appeal, you have a reasonable chance of receiving payment, if and only if, you have followed Medicare rules to the letter and you provide the necessary documentation on appeal to prove that ALL the rules have been followed AND there is no way for the patient to wear CPAP.  The problem is that the time and effort required to secure the documentation and file the appeals puts an amazing amount of work on your billing staff.  In my office, we are currently too busy to appeal each Medicare claim. So, we have each Medicare patient sign an ABN. The more difficult question is whether you require an ABN to be executed before you treat a Medicare patient.  We live in an affluent area where the majority of Medicare patients can proceed with treatment when required to pay cash. However, if you initiate this policy, a significant portion of your Medicare patients may be unable to finance treatment. Additionally, if the patient signs an ABN, CMS regulations require that you must use the appropriate modifier to designate that you have an ABN of file and any appeal of the resultant denials are almost always unsuccessful. It is equally important to inform your referring physicians of the consequences of this update and how it will affect their patients. It is possible that DSM may have received an unexpected benefit because of the March update, in that, it may be easier to document that OAT is ineffective, than document the ineffectiveness of PAP.  Only time will tell, however under RUL, OAT may be the best choice as first line therapy for mild to moderate cases. A discussion with your referring physicians could prove beneficial to your DSM practice. Ken Berley, DDS, JD, DABDSM Berley Consulting Bio: Dr. Ken Berley has practiced dentistry in Arkansas for over 35 years and practiced law for over 22 years and is licensed in Arkansas and Texas.  He is Diplomate of the American Board of Dental Sleep Medicine and a Fellow of the American College of Legal Medicine. For the past 10 years he has focused on the practice of sleep disordered breathing and has developed many of the forms and consents routinely used in sleep medicine.  Dr. Berley and his wife Patty, own Berley Consulting, providing mentoring, training and forms for those practitioners wishing to take their DSM practice to the next level. Jan Palmer, FAADOM Jan Palmer Consulting Bio: Practicing dental sleep medicine is a goal for many, but a reality for few. The complexity of the practice management in the dental sleep office and insurance reimbursement process has provided enough frustration that many dental offices abandon the potentially lifesaving and profitable area of practice. Educating on proper medical documentation and the break-down of policies for Medicare and private insurances has been my passion since 2000. In addition to national speaking and consulting roles, I work with the Provider Outreach and Education committee for Medicare DME for Jurisdictions A and D, have co-authored an e-book on Medicare, sit on the board of directors of the WNY Dental Managers Group, am a Fellow of the American Academy of Dental Office Managers, a facilitator with the American Academy of Dental Sleep Medicine (AADSM) Mastery Course, member of the Academy Dental Managers Consultants (ADMC), Dental Consultants Connection (DCC), Dental Codeology Mastermind Committee and the Dental Experts Network while maintaining a management position with a practice exclusive to treating sleep apnea, putting theory into practice every day.   Click Here for the PDF version of this article

Effective dentist and physician collaboration is key to addressing the underdiagnosis of obstructive sleep apnea and improving patient care and therapy compliance rates. For sleep dentists, forging relationships with physicians and becoming a trusted partner not only ensures patients receive optimal care but also helps dentists sustain and grow their sleep practice. Clinical practice guidelines[1] jointly commissioned by the American Academy of Sleep Medicine and the American Academy of Dental Sleep Medicine for the treatment of obstructive sleep apnea (OSA) through oral appliance therapy (OAT) underline the inherent need for effective collaboration between dental sleep medicine practitioners and physicians. While physicians—particularly sleep physicians—are charged with diagnosing OSA and prescribing appropriate treatment, sleep dentists have the specialized training and skills necessary to treat the condition with OAT. A strong bilateral partnership between the two practitioners is vital to ensuring the best possible treatment outcome for a patient. Common Challenges to Physician Collaboration Sleep dentists are likely to encounter a few common challenges as they work to build relationships with physicians in efforts to establish cross-discipline partnerships. A few of the most common challenges include: Challenge 1: Lack of Education about OAT Positive airway pressure (PAP) is widely acknowledged as the most effective treatment option for OSA, making it the gold standard for physicians prescribing treatment for the condition. As such, some physicians may be hesitant to refer their CPAP-intolerant patients due to questions or concerns about the efficacy of OAT or its potential side effects. Qualified, informed dentists should be equipped to discuss research that proves the efficacy of oral appliances as well as mitigation tactics for the therapy’s potential side effects. Challenge 2: Navigating Medical Insurance The medical insurance landscape is constantly changing and requires continuous effort to understand and adapt to policy updates, protocol changes, and reimbursement fluctuations. Whether it’s decreasing reimbursements for certain therapies, navigating the same-or-similar policies, or setting expectations about the out-of-pocket expense for patients, insurance changes often create challenges for the collaborative relationship between sleep dentists and physicians. To ease uncertainty and facilitate physician partnerships, dentists should keep referring physicians abreast of the in-network plans their practice accepts, as well as any strategies the practice employs to minimize the out-of-pocket cost for the patient. Challenge 3: Oral Appliance Manufacturers Bypassing Dentists Oral appliance manufacturers are always looking for ways to increase market share and provide their appliances to more patients. For some companies, these efforts have included bypassing sleep dentists entirely to supply physicians with appliances—and even going directly to the  patient by opening storefronts in major metropolitan areas. And while these tactics are certainly disheartening for sleep dentists, most physicians adhere to the clinical practice guideline that recommends that OAT should be administered by a qualified dentist. By making oneself an indispensable partner, dentists will enjoy continued referrals from physicians. Strategies to Facilitate Effective Physician Collaboration Despite the challenges, effective dentist-physician collaboration can be achieved with a bit of patience, persistence and by employing strategies that position the dentist as a trusted and knowledgeable partner. Strategy 1: Communicate with Physicians About Their Patient Thorough and timely communication with a physician about a referred patient is fundamental in establishing a trusted partnership. At minimum, a referring physician should receive communication—in the form of a fax, a letter, or both—at several key junctures: 1) when the patient has completed their initial consultation 2) when they’ve received their appliance and 3) when the patient is ready to undergo follow-up testing to determine efficacy of treatment. To foster additional trust and goodwill, many referring physicians appreciate receiving their first communication about a patient as soon as the patient has made their initial consultation appointment. Strategy 2: Send Patients Back to Referring Physicians for Follow-up A cardinal rule in the physician-dentist relationship is that the patient should always be referred back to the physician once the oral appliance has been titrated. Per clinical practice guidelines, physicians are responsible for determining efficacy of OAT and ensuring the patient’s condition has been adequately treated. Failure to refer a patient back to the physician is a sure-fire way to sully the professional relationship. Strategy 3: Outbound Referrals Create Even Stronger Partnerships Sleep dentists have the opportunity—and responsibility—to refer patients to physicians when the patient isn’t an appropriate candidate for OAT. Dentists are also uniquely positioned to establish relationships with an extended network of medical professionals, such as psychologists, ENTs, PCPs, and neurologists, who treat OSA comorbidities. Any partnership in which referrals are sent bilaterally significantly improves treatment outcomes for patients, strengthens the professional relationship of the practitioners, and elevates the profile of the dentist as an expert in the field of OAT. Effective dentist-physician partnerships are a fundamental part of the sleep medicine world’s quest to solve the problems of sleep apnea underdiagnosis and treatment non-compliance. Forging these partnerships can be a challenge for dentists but it is also a tremendous opportunity that, when done successfully, has a marked impact on patient treatment outcomes, as well as the success of the dentist’s practice. About the Author Dr. Kent Smith is board certified in dental sleep medicine and has been treating patients for over 30 years. He is a Diplomate of both the American Board of Dental Sleep Medicine (ABDSM) and the American Sleep and Breathing Academy (ASBA) and serves as president of the American Sleep and Breathing Academy. Dr. Kent Smith is founder and clinical director of Sleep Dallas, a dental sleep medicine practice with two locations in the Dallas metro area. [1] Ramar K,  Dort L, Katz S, Lettieri C, Harrod C, Thomas S, Chervin R. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015;11(7):773–827. Click Here for the PDF version of this article

Increase Accuracy and Improve your “Sleep Bite” with Ricketts Phonetic Bite. Given to you by the man who worked alongside of him for years – David Gergen Oral appliance therapy is considered an effective treatment for snoring and obstructive sleep apnea (OSA). The appliance functions by supporting the jaw in a forward position to help maintain an open upper airway. When utilized properly, it is worn at night and fits like a mouth guard used in sports. The success of the appliance, however, depends largely on the quality of the bite registration taken. While many view the process as an uncomplicated procedure, if it is not done using the correct technique with precision it could negatively impact the treatment. The late Dr. Robert Ricketts DDS, NMD was a well-known and arguably the greatest orthodontist of all time. A leader in orthodontic instruction, a professor and noted researcher in many areas of dentistry including craniofacial growth and development, TMJ, orthodontics and esthetics invented what is known as the the Ricketts Phonetic Bite. The Ricketts Phonetic bite may be used for patients suffering from snoring or obstructive sleep apnea and it determines the position of the mandible that creates the so-called sweet spot for patients using oral appliance therapy. This technique was invented by Dr. Ricketts in 1986, he trained Ed Spiegel. Dr. Ed Spiegel became the Godfather of Dental Sleep Medicine and went on to train hundreds of dentists in the field. INSTRUCTIONS ARE AS FOLLOWS 1. The dentist should instruct the patient to sit upright in the chair. 2. The dentist should instruct the patient to count out loud numbers 55-75. Notice numbers 5,8,9 for vertical opening and 66 for maximum anterior posterior positioning. If you do not get the desired AP with the “ss” sound, you can use the second “s” sound,”sh”to acquire the max AP. The “n” sound in 69 will drop their mandible vertically as well and give you their full natural opening The “n” sound is a straight vertical drop wherever you’re at in speech; using the word “shun” is another method for obtaining the best AP position. 3. The dentist should use a round surfaced instrument as opposed to a flat one (for anterior stabilization during the registration) between teeth #8 and #9 to hold that position of the jaw. 4. Use a fast set bite registration material to capture the bite. You will always want to start with having the patient occlude their teeth a few times in order to make a mentalimage of their natural occlusion. Having the patient counting those numbers should give you a feel for the most balanced yet natural vertical opening. All three types of basic classes of anterior occlusion must open to disclude the posterior teeth in order to allow a person to speak and when “ss” sounds must be made,at least 1 to 1.5 mm of clearance must be developed between the upper and lower centralincisors Note that saying “s” will not be sufficient; you will actually have to force the sound to occur using it in a word, as seen during the count in numbers that contain the “ss” sound or like with the word “Mississippi”. The amount of disclusion depends on the degree of forward movement of the teeth from centric relation to their “ss” position.These movements define the incisal guide angle and represent vertical and horizontal overlaps of the teeth. Thus, the greater the forward movement, the greater the amount of posterior disclusion and the resultant “s” space – or posterior speaking space as found in the number “66” and word “Mississippi”. Once again, repeat these steps a few times to make sure you get the same results. It is important to capture the optimum vertical as it is much harder to adjust after the appliance is fabricated.After using this technique, utilize the Airway Metric System by placing the correct jigs correlating with the sleep bite for reference lean the patient back in the chair and see if they can snore. If they cannot, ball game over. I specifically instruct doctors to only use the Ricketts Phonetic Bite with NFL players because of the accuracy and rate of success. For example, Super Bowl Champion Derek Kennard’s AHI went from a 72 to 2 on the first try using this technique. In 1991 Dr. Ricketts his personal CDT David Gergen trained Dr. Ed Spiegel in TMJ therapy and Sleep Disorder Dentistry. Demonstrated at the ASBA study clubs in a workshop setting. Visit ASBA.net This article was first published in 1995 on Dr.Ed Spiegels “Dental Innovation” booklets, training manual, and website. https://en.wikipedia.org/wiki/Robert_M._Ricketts

A thriving dental practice often resembles a juggernaut with little time or inclination to go outside of traditional dentistry, but branching out requires a willingness to slow down, be patient, and pursue education. Chris M. Chui, DDS, MAGD, DASBA, puts it this way: “Rome wasn’t built in a day. You must plan, learn, and know that sleep medicine is very different than regular dental procedures.” And while it’s not simple, Chui believes all dentists can learn the basics. As a clinician with multiple private practice locations in the Bay Area, that learning took place over many years. Now after a decade building the sleep side, referrals are plentiful and colleagues across medical subspecialties understand the value of oral appliances, while also appreciating Chui’s extra devotion to education. “If you want to be proficient in treating patients with sleep apnea, and ask other colleagues to refer to you, getting diplomate status is something you have to do,” he says. “You can treat one or two patients a year or a month, or five to 10 per month. The diplomate status can help you get more patients, and it demonstrates you have a certain level of knowledge compared to other dentists. It’s vitally important.”  Attaining the diplomat status is more than just a new title. It represents your determination, dedication, and devotion to this unique branch of dentistry. It also represents your confidence and proficiency in the subject of Sleep Apnea that helps you build trust and faith from other healthcare professionals. Chui rejects any notion that it’s too late for dentists to add a new wrinkle to their practices. With educational offerings from organizations such as the American Sleep and Breathing Academy, the challenges of insurance reimbursement and building the practice benefit from a growing cadre of dentists using best practices. Furthermore, ASBA is a great place to connect likeminded dentists to come together to cultivate interests and share knowledge of sleep, which is extremely important for everyone who has determined to help their patients more than just their dental health. ASBA will provide a platform for any dentists to come and learn to improve the overall health and wellness of their patients. “We probably have some work to do in continuing to properly educate the public,” says Chui, who attended the University of California, San Francisco. “We need to educate the M.D.s, and network with them. Communication is the key and sharing your treatment results to the mutual patients can be challenging yet rewarding. Physicians like to know the status of their patients and it’s imperative that you need to inform them about the success and failure of the treatments. This is the key to referrals from physicians.” According to Chui, the biggest challenge among dentists to learn how to treat sleep apnea can be multifactorial. However, we can basically identify some factors that can be easily targeted: The most common factor that discourages dentists to practice sleep treatment is definitely a lack of knowledge and training. Dentists needs to take more CE courses. The science of Dental sleep medicine is changing everyday and dentists need to understand that educating themselves constantly is the key to success. You need confidence and expertise to speak with physicians and make crucial connections with sleep doctors. “The more you learn, the better your confidence”. We need to show others our devotion to the subject of sleep and we have to be assertive and confident. We are here to educate the public and other healthcare professionals. The more you practice, the more unruffled and convincing. Too often, dentists lack endurance and persistence. They may get discouraged and stop, but you need to continue and persist. Patience is virtue! We cannot expect to build the sleep program simply by taking a weekend course. You need to build your teams, educate them about sleep dentistry. Lack of time is probably the most important factor. A lot of dentists are so busy doing root canals and implants, but you need time to devote to sleep and build that side of the practice. You can’t build the practice without putting in that time.” Stay focused and spend time developing your program. It will not help if you simply delegate all the jobs to others, but if you do not want to devote your time and energy to it, you will not be successful. Be open-minded with learning the basis of medical insurance billing. It is not easy; however, it can be learned and dedicated third party billers can be your greatest ally to success. Chris M. Chui, DDS, MAGD, D-ASBA