Sleep therapy continues to receive scrutiny by regulators and payors. Centers for Medicare and Medicaid have been monitoring patient outcomes and clinical yield for patients. There has been no formal announcement as to their findings however CPAP reimbursement continues to be cut while Oral Appliance Therapy reimbursement has officially been increased by Medicare. Revenue from code E0486 has doubled in recent months according to reports by ASBA members, Industry leaders predict that private insurance will follow Medicare reimbursement guidelines.
Supporting this trend is the recent announcement by Cigna the first private insurer to develop a national policy for Oral Appliance Therapy, settling on $2500 as a bundled fee. In other regions fees have increased by 25 to 100%. Jurisdiction “D” reimbursement rates has remained unchanged.
Insurers are expected to work with industry to monitor outcomes data to balance revenue and patient care expectations. It is also very significant and important to note that evidence of post graduate training and Diplomacy has become a method that some insurers use to deny insurance claims (this is new and bears watching).
The American Sleep And Breathing Academy continues to monitor insurance reimbursement, and policies through its relationships with Washington DC insiders like Congressman Marty Russo and others.
“In June of 2015 the ASBA was the first organization to warn Dentists of the risk to using the “S” code for billing TMJ Splints. Advance notice of this change saved ASBA members thousands of dollars in hard costs associated with billing errors and uncollected revenue.” – David Gergen CDT
The latest opportunity identified by the American Sleep And Breathing Academy team of lobbyists is a new government protocol for chronic care management. CCM has the potential to contribute a strong revenue stream for sleep apnea dentists in 2016. The physician who developed the Chronic Care Program spoke at the Sleep and Wellness conference in Scottsdale AZ April 15 and 16.
A running discussion for the last 6 years here at Gergens Orthodontic Lab has been the CPAP as Gold standard of sleep therapy vs Oral Appliance therapy debate. These discussions usually go for hours and have gone on for years. The strongest debate has been between David Gergen President of Gergens Orthodontic Lab and Executive Director of American Sleep and Breathing Academy (ASBA) and Randy Clare who supports CPAP. Gergen knows CPAP has its place and time in the sleep world, but strongly feels that the oral appliance will surpass CPAP as the go-to treatment within 10 years. Clare would debate if that’s the case, respiratory techs will be managing the oral appliance patients not the dentists. Back and forth compliance vs treatment efficacy. David Gergen has been back and forth to Washington working with congressman Marty Russo trying to get some traction within the federal government on this issue.
The key point of distinction of course is what drives medical care in the United States is reimbursement. The story for CPAP in the reimbursment arena since competitive bidding became an issue has slowly restricted access to care and fed a consolidation of providers. Fewer providers to provide care and the care they can afford to provide is less personal which results in lower compliance rates which results in lower reimbursement. January 1 2016 CMS cut CPAP reimbursement by 25%. Will this affect a diagnosed OSA patients ability to get great care of course it will.
On the other side of the ledger Oral Appliance therapy has not been a focus for CMS. The OAT program has been way underfunded. This has made access to oral devices for sleep apnea difficult for medicare patients. Dentists were not finding it easy to provide care for these patients because reimbursement was so low. January 1 2016 CMS raised reimbursement for OAT to $3700 in jurisdiction B (see attached EOB
) If you don’t know your jurisdiction for medicare I have also added a map
for your use.
I expect that this will increase access to care significantly. I feel it indicates a trend and perhaps insurers are ready to consider higher compliance rates and better return on sleep therapy dollars. After all the dental team sees the patient at minimum every six months which is a much better way to manage a lifelong condition with severe health implications.