Dental Sleep Medicine Insider March 2017 | Page 28

LESIA CRAWFORD

DED , EOB , WTF ?!?

DED
Abbreviation for “ Deductible ”
This is how much money the patient is supposed to spend out of their pocket until the benefit of insurance actually starts . Some plans have doctor visits and preventive care available that is not subject to the deductible . We are not in that group ; for us , deductibles usually apply only to OAT .
FAM DED
“ Family Deductible ”
This means that each family member has their own deductible to meet , but there may be a limit or cap and once it is met by any family member it starts benefits for the whole family . For instance , the plan has a $ 1500 individual deductible per covered family member and a $ 3000 family deducible . Mom has a baby , met her $ 1500 deductible , Johnny crashed his bike and had 5 teeth knocked out and implants , bone grafting and implant crowns are placed and he met his $ 1500 deductible . Dad goes in for a sleep study and gets an oral appliance to treat his sleep apnea , he does not need to meet his deductible because the family deductible has been satisfied . Get it ? Got it ? Good !
OOP MAX
“ Out of Pocket Maximum ”
This is a fun one . That ’ s sarcasm . Once the patient has paid their deductible and had medical services done and paid a % of the bills , the insurance company is willing to pony up at 100 % coverage once this maximum amount of money paid out of pocket has been met . Depending on the plan this might be $ 1500 . It might be $ 5k , $ 10k ; it just depends . It serves as a safeguard so a patient will not go bankrupt for medical treatment …. until next year that is when they all re-set .
EXCLUSION FOR DME
Unfortunately , we have run across some medical plans that have an exclusion for some or all DME supplies . When we call for a benefit verification or use an online tool we are specifically looking for the DME benefits , as they could be different then traditional benefits and services . If the Medical plan has an exclusion for DME supplies , do not assume the representative is aware of what specific DME supply you are referring to . The plan may not pay for crutches and boots but If CPAP is covered , then OAT should be as well .
MEDICAL NECESSITY
This is an unknown term in dentistry but to your medical biller , this is the golden key for approvals and insurance payments . Translated to dental , proving “ medical necessity ” would equate to “ proving need for dental treatment .” Let ’ s say tooth # 3 needs an MOB composite filling . Decay can be proven with an x-ray and visual exam . The dentist diagnoses and documents the problem , then plans the treatment . It ’ s the same idea with sleep medicine but the burden of proof is called “ medical necessity .” The patient was screened , tested , diagnosed and then a plan for treatment was given .
LOMN / RX
Expounding on the previous definition , the letter of medical necessity and prescription for treatment ( LOMN / RX ) is the actual key . This letter , or form , spells out the patient ’ s diagnosis and co-morbidities and then explains the need for treatment and outcome if the condition is not treated . It should also list the name of the physician ordering the treatment and the providing dentist . Length of
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need for treatment should be listed as lifetime . DS3 has the perfect template form built right into the software as well as a cover letter that can be easily sent to the primary care doctor or sleep physician .
EOB
This one is the same in Medical as it is in Dental , “ Explanation of Benefits .” The EOB should list the patient ’ s and subscriber ’ s names , the treating doctor ( that would be you ), the date of service and itemized procedures and fee ’ s . It should also list the “ allowed amounts ” or negotiated fee , the patient deducible , patient co-pay and amount paid to the patient or the provider .
Congrats ! You are now fluent in medical billing-ese or at least you can understand what your medical billing company is talking about . If you would like a sample letter of medical necessity please email me and reference this article .
lesia @ gogobilling . com