Dentists who aren’t in-network with medical insurance can request one-time approvals when no other OA providers are in-network either. An expert shares a sample letter and tips to increase the likelihood of a successful outcome.
Do dentists need to be in-network with medical insurance to receive reimbursement for oral appliance (OA) therapy? The answer, perhaps surprisingly, is no. Many dentists who provide OA therapy successfully bill medical insurance, despite their out-of-network status.
As a consultant, I’m frequently asked general questions about successful medical billing for dentists. The most common question revolves around how to navigate the high deductibles that we frequently see. The good news is there is a solution called a “network gap exception” that you can implement immediately to help reduce patients’ out-of-pocket costs. Starting with a telephone call or letter from the dental office, many insurers grant this exception, so patients may more easily receive the medically necessary care they need.
What Is a Network Gap Exception?
A network gap exception is designed to compensate for “gaps” in an insurance plan’s network of contracted providers. A request for an insurer to honor a patient’s in-network benefit as an out-of-network provider is submitted to the insurance company. Typically, an insurer will allow a gap exception if there is no other provider who can offer the service within a reasonable distance of the patient’s home. Most insurers will set this “reasonable distance” between 30 and 40 miles but it varies.
What Are the Benefits of Receiving a Network Gap Exception?
A patient will often pay a higher deductible and copayment when receiving care from an out-of-network provider. A gap exception basically is employed when a patient wants to use in-network benefits, but there is not an in-network provider the patient can go to for care. If there isn’t an in-network provider in the plan, the insurer will typically grant your request.
If an in-network provider is available, they will tell you (and deny your request for the gap exception). But keep in mind that the providers who insurers have on network lists might not actually provide oral appliance therapy. So if you are told there’s an in-network provider, it’s important for your practice to check that the provider truly does offer the service, in this case, an oral appliance for obstructive sleep apnea (OSA). For example, an in-network oral surgeon may provide oral surgery for OSA but not oral appliances. And in-network durable medical equipment (DME) suppliers who provide PAP therapy are not qualified to deliver oral appliance therapy. If you discover that the in-network provider cited does not actually provide oral appliances for OSA, point this out to the insurer; the insurer will then often grant the gap request.
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Sample Gap Request Letter for Oral Appliance Therapy
To: Sleep Claims Insurer
Re: Megan Brzezin
DOB: 3/18/1976
Insurance ID#: 1234567
Dear Insurance Authorization Representative:
This letter is to request a gap exception (out-of-network exception) authorization for the above-named patient for oral appliance therapy for obstructive sleep apnea (OSA). The patient has refused or is intolerant to nasal CPAP and was referred to our office by her physician. Following our examination, it was determined that the patient is a good candidate for oral appliance therapy to manage her condition.
There is not another in-network dentist appropriately trained to provide this treatment in our patient’s geographical area. Mrs. Brzezin would like to be able to utilize her in-network benefits. As there is not an in-network provider for her who can provide this medically necessary treatment for her OSA, we are requesting a network gap exception authorization for treatment.
Thank you for your prompt attention to this matter.
Sincerely,
Sleep Apnea, DDS
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Tips for Receiving Gap Exceptions
Rose Nierman, RDH
- Start the gap exception authorization process with a telephone call to the insurance verification department. A preauthorization for oral appliance therapy and the gap exception are frequently processed in tandem, often by fax.
- Gap exceptions are granted on a one-time basis—it is not a blanket authorization for all your patients.
- Once the gap request is started by the dental office, many insurers ask that the patient call to request the gap exception.
- Other terminology for the gap exception includes “network deficiency,” “network insufficiency,” or “gap waiver.”
- Many HMOs [health maintenance organizations] and Medicare Advantage insurance plans, as well as PPOs [preferred provider organizations], grant gap exceptions.
- Your practice can apply for gap exception authorizations not only for oral appliances for OSA, but also for temporomandibular joint (TMJ) appliances.
- If you receive a gap authorization denial stating there are in-network DME suppliers within a reasonable distance to the patient, appeal the decision on the grounds that it is not the correct provider type for oral appliance therapy.
A recent survey of Nierman Practice Management clients revealed that gap exceptions are granted more than 60% of the time for oral appliances for OSA. Some practices report up to 80% to 90% success rates in their gap requests.
When a patient is intolerant to PAP therapy, oral appliance therapy is not just a convenient option; it’s a medical necessity. Take the extra time to jump-start medically necessary care by requesting gap exceptions. Your patients are counting on you.
Rose Nierman, RDH, is CEO of Nierman Practice Management, a continuing education and software company with a 30-year track record of helping dentists implement medical billing, dental sleep medicine, and TMD treatment. Nierman’s cross-coding and sponsored clinical courses have helped thousands of dentists and their teams. Contact Rose Nierman at rose[at]dentalwriter.com or 800-879-6468 or visit www.niermanpm.com.
How do you feel about getting paid in full upfront and having insurance reimburse the patent? I’ve had a few cases that insurance ended up not paying or didn’t reimburse as expected. And I’ve had patients that decline tx due to upfront costs.
Tom, That’s a great question. We work with some dentists who are fee for service. Other practices find that it works well to preauthorize oral appliance therapy and collect the deductible and copayments upfront. I hope this helps!
When we are granted the “gap exception” are accepting the in network fees as well? Or are we allowed to balance bill our UCR?
Rose,
I’m a patient in a similar situation. the doctor wants the entire payment up-front. I’d like to know, in your experience, what is the general probability of insurances approving such requests and does the insurance reimburse the patient or the doctor? Is it also advisable to obtain a note with doctor’s signature for a guarantee of reimbursement IF the insurance ends up sending them the money instead of the patient. thank you.