Y our patient is suffering from
OSA . She is feeling the negative health issues associated with it , and she ’ s gotta have treatment . You know which device you ’ re going to provide based on her presentation , but do you know what documentation you must have for insurance approval and payment ? Insurance companies have their denial stamps inked and ready for your file . You can bypass that ugly red “ DE- NIED ” stamp and sail toward an approval letter and the accompanying payment if you provide the necessary documentation .
She ’ s gotta have treatment , and you ’ ve gotta have these 3 items .
1 . Diagnostic sleep study report with the diagnosis code G47.33 listed . The study must be signed by a board-certified sleep physician to be a valid study . A split study is also accepted with the baseline AHI and or RDI listed . Ideally , the sleep study should be less than 2 years old , but we have seen some plans accept older ones .
2 . Proof of co-morbidities based on the patient ’ s AHI . In other words , something else associated with their sleep apnea because not breathing 10 times an hour is not bad enough to warrant some treatment according to most plans . Below is the GoGo Billing AHI cheat sheet .
GOTTA HAVE IT ;
a . 0 to 4.9 : No insurance coverage as the patient has not been diagnosed with OSA . You can treat the patient for snoring and have them pay cash .
b . 5 to 14.9 : Co-morbidity is NEEDED ! Submit documentation of one or more of the following ; excessive daytime sleepiness with an Epworth score of 10 or above , high blood pressure , mood disorders , impaired cognition , insomnia or ischemic heart disease , or history of stroke
c . 15-30 : The safe zone , no co-morbidity is needed .
d . AHI : 30 +: No co-morbidity is needed BUT you will need an intolerance to CPAP affidavit signed by the patient .
3 . An RX or letter of medical necessity ( LOMN ) signed by a physician .
DS3 offers a perfect template within the “ forms ” section of the software to capture this information . Another idea would be to have referral slips / RX pads custom made to give to your referring physicians . Ideally the RX is signed by the treating sleep doctor but the primary care physician , or any treating MD , DO , or NP can also sign the RX for treatment . This is not a barrier to treating your patient , but it is
LESIA CRAWFORD
3 INSURANCE MUSTS FOR EVERY OAT CASE
Lesia Crawford , CEO of GoGo Billing
Contact me at Lesia @ GoGoBilling . com or call ( 877 ) 874-4646 ext . 1
an opportunity to market your services and establish essential communication with potential physician referral sources .
Gathering these 3 components for your case files will ensure approvals and payments with almost all plans . If you would like a copy of my referral pad template , I am happy to share it with you . Just email me at Lesia @ gogobilling . com .