By Risa Kerslake, RN, BSN

Several decades ago when Gy Yatros, DMD, DABDSM, started in dental sleep medicine, medical insurance rarely covered oral appliances for obstructive sleep apnea. Now that awareness and coverage have grown for this CPAP alternative, dentists are learning how to help patients apply their medical insurance benefits. 

Jon Nierman, too, has seen more dentists venturing into medical billing for sleep medicine. Nierman, president at Nierman Practice Management, estimates that 20% to 25% of dentists now offer dental sleep medicine services. “It’s not across the board and not something that they are trained on in dental school—that’s just now starting to happen,” he says.

But medical billing comes with a steep learning curve. SOAP—Subjective, Objective, Assessment, Plan—notes can be particularly problematic for dentists. Inefficient and incomplete SOAP note practices often lead to claim denials and reimbursement delays in oral appliance therapy.

Documentation Challenges

As dental sleep medicine practitioners add medical billing, “we see a lot of claim denials because they’re used to their regular dental documentation, which isn’t going to show medical necessity the way a proper SOAP note would show,” says Nierman, who markets the cloud-based electronic medical record software DentalWriter Plus to facilitate medical billing.

Medical insurance policies require documentation of criteria such as excessive daytime sleepiness, comorbidities, and no contraindications for oral appliance therapy, Nierman explains. If these details aren’t clear in the notes, the insurance company can deny the claims. 

When documented properly, “I would expect an office to have a 90-something percentile rate of success,” says Joe Magness, DDS, CEO of Devdent, which markets Imagn software to overlay practice management software to support dentists who offer oral appliance therapy.

Collaborating with Sleep Physicians

According to Anjoo Ely, DDS, DABDSM, SOAP notes allow for clear, concise communication with physicians. “To grow your sleep practice, you have to be able to speak the same language as them, and that SOAP note is the foundational piece that’s needed,” says Ely, a dentist at Novi Sleep & TMJ who uses Nierman’s Dental Writer Plus in her practice. “We have a medical diagnosis, and then you have a dentist providing the solution. That’s where the bridge between the notes from the dentist, the notes from a physician, and the medical insurance being the reimbursing party all come into play.”

More Efficient SOAP Notes

It’s not practical to handwrite every SOAP note—it is more efficient to auto-generate it by filling in information, according to Cristy Plain, RPSGT, CCSH, vice president of operations at Dedicated Sleep, a specialty medicine practice group that markets DS DediCare, a cloud-based electronic health record software.

Plain says dentists need to understand the questions to ask insurance companies to determine coverage and reimbursement requirements. Also, “if you don’t include all of the steps, the medical side looks at it like you didn’t do a complete exam, that you really don’t know the person you’re about to treat,” she says.

At Imagn software, its purpose, Magness explains, is to help up efficiency in documentation, as well as facilitate claim follow-up and payments. It is organized so dental offices can screen a patient and document objective findings by clicking through buttons, creating a SOAP note in medical insurance-approved format.

Nierman’s Dental Writer Plus also solves the problem of documenting medical necessity, including SOAP notes. “It’s not a template for the SOAP report—instead, every checkbox that’s entered in becomes a custom sentence that builds the detailed SOAP report for that patient based on the exact findings in the chart,” Nierman says.

Dental Writer Plus also generates patient intake forms. For example, patients can fill out the Epworth Sleepiness Scale online and it’s imported into the electronic chart. Sleep study results from physicians can be scanned in. “It’s easy at that point to add different providers that you want to send that SOAP note to, so you can just enter their fax number and get it sent. It’s pretty streamlined,” says Ely.

But Nierman cautions on record cloning—cutting and pasting past patient information from a prior SOAP note to a new note. Using standard and predetermined notes while only changing some numbers puts an office at risk if the insurance company decides to do an audit.

If searching for a company offering sleep medicine solutions, request to talk to a local dental office or a practice that’s just getting started with the company to ask how it’s working for them. “They really need to get more comfortable with it because if they dive in deep and don’t know how to get paid, they get overwhelmed,” says Plain. 

Reducing Administrative Burden

Yatros, who is the founder of several companies, including Dental Sleep Solutions, which markets DS3 Software to help with reimbursement and workflow, says the administrative processes and the need for specialized billing and software are crucial for success.

Though if dental practices aren’t using software, they should at least have a good questionnaire in exam form, Nierman advises. “You want to make sure you’re getting the right information that’s going to help show medical necessity when it’s time to send it to the insurance company,” Nierman says.

While many dentists utilize assistants in the exam rooms for documenting care on the computer, Plain says some still don’t have a computer in the room and instead use paper to hand over to office staff to put in the system. “It’s so inefficient. Invest in an inexpensive laptop, do your exam at the time so you’re not missing something. Keep the technology as efficient as possible,” says Plain. 

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