I thought it would be just another presentation until I stood before the group and saw first handed the dynamics and heartbreaking challenges they live with – everyday. Easter Seals provides a yearly meeting for parents of Down syndrome children, and this year they had invited me to give a presentation entitled “Sleeping with Down syndrome.”

Parents of Down syndrome children deserve to be applauded and served well  by all of us.  From birth their child/children suffer with classic OSA symptoms which

often go unnoticed and undiagnosed.  DS children usually have short, wide necks, the airway is narrow making breathing difficult; the tongue is enlarged and swallowing is continuously problematic; the weak muscle tone (hypotonia) from infancy adds to the probability of OSA.

Throughout the presentation, I struggled to keep my emotions ‘in check’ as the facial expressions of each parent seemed to grasp the little bit of hope offered through oral appliance therapy. As the ‘teacher’ for the moment, I became the student, realizing the true struggles this often-ignored and unnoticed group of people encounter each day. Though there is no cure for DS, we as dentist have the training and ability to offer some relief that can make an enormous difference in their world and ours. An estimated 250,000 people in the United States have this condition; Down syndrome occurs 1 in every 830 newborns. Source: http://ghr.nlm.nih.gov/condition/down-syndrome

At the close of the presentation, Tom anxiously approached me and introduced himself as one of the proud fathers of a DS child. Tom then proceeded to tell me his story, “Everything you said described me.” He continued: “I’m an executive at Caterpillar (world headquarters located in Peoria, Il) and I struggle to stay awake throughout the day. I fell asleep at a stoplight, waiting for it to turn green, so my wife began driving me to work. We have 8 children so this was difficult for her.  A few years back, my doctor recommended nasal pillows with a chinstrap; I couldn’t tolerate the chinstrap so my doctor put me on a full face mask, the pressure was at a 22 and complications set in and I found myself unable to were it.

My doctor then recommended our last option, the UP3 surgery. I knew it would be a difficult surgery, but I was desperate and felt like this was my last chance.  The surgery helped for a short time, but then the drowsiness returned.  Last week I fell asleep in the middle of my sentence while talking to a co-worker. My wife and I have decided that I need to retire and apply for disability.” Tom was 51 years old with a great career and large family responsibilities.

A report from Health Advocate explains Tom’s case very well: “Sleep deficits in general are lined to an increased risk of cardiovascular disease, stroke, obesity and hypertension.  These chronic conditions are a major factor in soaring healthcare costs for U.S. companies accounting for 70-80 percent of their overall healthcare costs.” Another eye-opening statement from the same report says: “The effects of sleep loss on work performance are costing U.S. employers tens of billions of dollars a year in lost productively.  Its time for American workers and employers to make sleep a priority.”

My first concern was that Tom was untreated and needed help now. The following day, Tom presented as a patient in my office and we began MRA treatment.  His AHI score was 115.  We delivered his appliance and he returned for his two-week follow up my office.  He was driving again and looked like a different man!  Tom was elated, but I knew he was still in danger so I called his pulmonologist and arranged for a split night PSG using the appliance only for the first part of the test. Tom’s AHI was reduced to a 31 with the appliance alone, then a minimally invasive CPAP(nasal pillows only) combined with the Herbst MRA was titrated and the final AHI was reduced to a 4 with the CPAP pressure at a 10.

In the eyes of the pulmonologist, I wasn’t just a dentist, but rather a sleep specialist, which I could not claim. He saw me as this due to my stand-alone sleep practice, which has my complete focus. We began a series of conversations and determined the best treatment for OUR patient was a combined therapy approach. With the oral appliance in place and functioning as the ‘work horse’ we applied nasal pillows and brought his AHI to a 4. It is important to note that the appliance had to be perfect; I use Gergens Orthodontic Lab because I can depend on the consistency of the product they provide. Combined therapy was the right choice for in this case and I continue to evaluate combined therapy for every case.

At Tom’s one-year recall appointment his AHI was stable at a 4, the appliance was doing all that it is designed to do.  Tom was on his game at work and at home. His wife was no longer driving him to the office and he was staying awake during family time. Conversations about disability were history! As I walked out of the treatment room Tom stood up, put his hand on my shoulder and said, “Wait a minute Doc, I just want to say thank you for giving me my life back.”

Quality of life is more valuable than position, titles, or money. When we, as dentist, can change the course of a life due to treatment that is within our means to provide, what a privilege!  It also heightens our responsibility to society and building relationships with all medical providers.

 

David Gergen CDT opened his family-owned Gergen’s Orthodontic Lab in Phoenix, AZ in 1986 and now employees over 80 people. David Gergen has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also received a lifetime achievement award by Dr Harold Gelb Academy as Americas greatest Orthodontic technician of all time, in 2012. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. Gergen and his father John Gergen began Gergen Orthodontic labs in 1984 and have grown it into one of the most respected labs in the country. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004. David is the Dental Director of the American Sleep and Breathing Academy and he has also taken a spot at Tufts University teaching seminars for the Continuing-Ed program on Dental Sleep Medicine.

 

 

Sleep Apnea Dentistry is perhaps the fastest growing part of my life. In my career I have always associated with the best dentists in the country. In my travels I have heard one question over and over again “Is a dedicated sleep practice right for me?”. The other question is “How will I know when to make the jump to a sleep only practice?”. This is the second installment of a 5 part series.

I asked Dr. Willey to write up his journey in sleep medicine, from the early days of training with Dental Sleep Medicine Pioneer and Legend Dr. Ed Spiegel. Being the person Dr. Willey is, days later I received a call from him, he said ” David I want to tell a five part history from the being leading up to my lecture in Scottsdale” from the very beginning. He told me he could do it in a five part series on his personal journey, here is part one. Remember at the American Sleep and Breathing Academy Dental meeting in Scottsdale AZ April 10-11 www.asbadental.com he is going to explain how he built the largest dental sleep practice in the United States, 2.5 million a year and 106 appliances in a single month.

IS A DEDICATED SLEEP PRACTICE RIGHT FOR YOU?

Part 2 – ‘Building an Alliance’

 

I finally had an opportunity to meet him. Recognizing the connection between my practice of obstructive sleep apnea and his practice of Ears, Nose and Throat, Dr. Holland was someone with whom I wanted to build an alliance.  Our office had made numerous calls in an attempt to set up a meeting and finally, we were in! Our conversation went well, both of us realizing that our philosophy for treating patients were symbiotic. As I left his office, I couldn’t help but think, “The real test will be IF he refers any of his patients to me.” As the months went by, he sent many referrals to me and soon became one of my largest referral sources and continues to this day.

The reason for his referrals had little to do with my reputation, location or credentials. It had everything to do with his perception that I was a sleep specialist (though I could never claim this title) because I

limited my practice to OSA and TMD.  And, because I was practicing in a medical model just like he was. The medical model was key, meaning that I accept most all medical insurance and Medicare.

Many dentists are interested in providing sleep and/or TMD appliances to their patients, but the amount of work to get payment for these services seems overwhelming, even with software specifically designed for dental sleep medicine.

Jumping into the medical world can seem easy at first glace. It’s just a different claim form, right? Wrong. Most doctors aren’t aware of the risks of not asking the right questions on the pre-verification phone call and having all the necessary documentation on file. For instance, a dentist can bill a claim for the E0486 (OSA appliance) to Medicare and may see an immediate payment without records ever being requested. The issues come when Medicare decides to do an audit, which is guaranteed to happen.  If all documentation is not in complete order prior to impressions being taken, Medicare will ask for the money back and require it in a lump sum.   There could also be fines for non-compliance as a Medicare provider.  As you are well aware, this can completely bankrupt a practice.

I personally experienced a Medicare set back when I first began.  Our office staff had been trained that the x-ray we were taking on all our patients would be covered by Medicare.  When we started receiving denials for these x-rays, and realized that Medicare would not pay due to our provider type, we had to write off all charges.  As a Mediare provider, it is our responsibility to know what will be covered and what is not a covered procedure.  Fortunately our practice was in the beginning stage and it was early enough that my set back was minimal and I was able to appreciate a hard lesson well learned.

Medicare requires that all participating physicians convert to Electronic Health Records by 2015. A monetary penalty will be assessed if not fully in compliance. Certified software specific to dental sleep medicine is a must. In order to bill an evaluation and management procedure code, certain criteria must be met. Each visit must be evaluated prior to coding. This is important to prevent a Medicare trigger resulting in an audit. I found that audits are not only time consuming but drastically slows down payment flow.

Calling an insurance company for a pre-verification of benefits shouldn’t take a scientist.  Unfortunately, depending on the question, the representative interpreting the information, and the way the question is asked, wrong information can be given resulting in unhappy patients and a loss of money for the provider. Even if a code is “billable,” it may end up being denied.  I am thankful to have a dedicated billing department who understands the pre-verification process and the requirements necessary for maximum insurance reimbursement.

Being a Medicare provider carries much responsibility. When auditing records, Medicare can look into ANY patient, not just Medicare patients. What you do for one, you must do for all. Guidelines on insurance fraud, professional courtesy, and write offs are closely monitored. Medicare, Medicaid, and Tricare are all government agencies and any penalties or charges are a federal matter.

Another factor in building an alliance with specialist in the medical world is providing them with a sample of the appliance you are providing for patients.  I found that if I hand them an actual appliance they will recognize the difference between what we offer and what the local Walgreens and CVS stores offer over the counter.  When I provide them with a Gergen’s Lab appliance, it is impressive and professionally packaged.  Month after month I have the privilege of seeing 35-50 OSA/TMD patients every day, it is imperative that I can depend on my lab to ensure my reputation with my alliances is secure.

 

David Gergen CDT opened his family-owned Gergen’s Orthodontic Lab in Phoenix, AZ in 1986 and now employees over 80 people. David Gergen has been a nationally respected dental lab technician for over 25 years. He received the award for “The Finest Orthodontic Technician in the Country” given by Columbus Dental in 1986. He also received a lifetime achievement award by Dr Harold Gelb Academy as Americas greatest Orthodontic technician of all time, in 2012. He has worked for some of the pioneers in the orthodontic and sleep dentistry fields. Gergen and his father John Gergen began Gergen Orthodontic labs in 1984 and have grown it into one of the most respected labs in the country. One of his proudest achievements is receiving The National Leadership award for Arizona Small Businessman of the Year in 2004. David is the Dental Director of the American Sleep and Breathing Academy and he has also taken a spot at Tufts University teaching seminars for the Continuing-Ed program on Dental Sleep Medicine.

 

 

Sleep Apnea Dentistry is perhaps the fastest growing part of my life. In my career I have always associated with the best dentists in the country. In my travels I have heard one question over and over again “Is a dedicated sleep practice right for me?”. The other question is “How will I know when to make the jump to a sleep only practice?”.

I asked Dr. Willey to write up his journey in sleep medicine, from the early days of training with Dental Sleep Medicine Pioneer and Legend Dr. Ed Spiegel. Dr. Willey let me interview him on his success and that is what he will be speaking on at the American Sleep and Breathing Academy Dental meeting in Scottsdale AZ April 10-11 www.asbadental.com . Being the person Dr. Willey is days later I received a call from him, he said ” David I want to tell a five part history from the being leading up to my lecture in Scottsdale” from the very beginning. He told me he could do it in a five part series on his personal journey, here is part one. Remember at the American Sleep and Breathing Academy Dental meeting in Scottsdale AZ April 10-11 www.asbadental.com he is going to explain how he built the largest dental sleep practice in the United States, 2.5 million a year and 106 appliances in a single month.

 

 

If I knew then…  

 

“And what do you do for a living Joe?” “Purchasing agent for recreational pharmaceuticals” he replied with a wink and an unforgettable grin. Joe was a police officer and loved his work, and he never hesitated to share a good story of their newest hit on the streets.  I had the privilege of working with Joe’s wife, Sarah, for 22 years, she was a powerhouse assistant and though patients might miss a chance

to see me, they never missed a chance to see Sarah!

I wish I could say she was on top of her game every day, truth is, she wasn’t. She would come in with her hands wrapped around a cup of coffee as though it were her security blanket for the day. And then I would hear the same old same old, “Joe was snoring so bad last night, I hardly got a wink.” Following her comments, someone would always have something to say to make everyone laugh. This went on week after week, year after year.

And then the dreaded phone call came, “Doc, can you come- Joe died in his sleep from an apparent heart attack.” Racing to their home, I arrived and joined the many other mourners.  Nothing made sense. Joe was a 40-year-old and in top physical shape.  Sure, there were a few thugs who didn’t care for his career – but there was no sign of struggle or foul play. Sarah was never the same, nor I was.

Several years later, I was taking a weekend course on “Sleep Apnea.”  And the pieces began to come together, all I could think of was Joe. I begin my search into dental sleep medicine with a determination to learn everything I possibly could and it wasn’t long until I knew that had I known then what I know now, Joe would most likely still be with us. From that moment on, dentistry changed for me. I began seeing my role differently and it wasn’t long until I was weaving sleep appliances in-between general dentistry and I always had a ‘win.’ Using Gergen’s Orthodontic Lab my cases were perfect, and that’s exactly what I was looking for.

I began experiencing a new fulfillment and I wanted more. Several patients that I had done a CBVT and radiologist read on were diagnosed with life threatening situations and their physicians called me to commend the find. Along the way a new group of challenges began to surface. I would look up to see my hygienist tapping her foot in the entrance of a treatment room, reminding me that I was spending too much time with ‘the sleep patient’ and it was sabotaging her schedule.  Though being a multi-tasker was a natural for me, I was struggling to keep it all flowing – perio, implants, pros, cosmetics and … Sleep. The sleep patients needed much more time and focus. And I had to choose between changing a life and saving a life. So I chose. In a very short period of time, I sold my dental practice and began a dedicated sleep practice. This is what I found:

1. Physicians looked at me differently – I was no longer a dentist to them but a sleep specialist. (Though I could never claim this title)
2. In a dedicated sleep practice, I didn’t miss a single OSA or TMD diagnosis because that’s all I did.
3. Working within the medical model and accepting medical insurance is challenging but necessary.
4. Undiagnosed sleep apnea was all around me, and I realized there are a lot of “Joe’s” that needed my services.