Clinical GAP Exception Most dental practices are out-of-network providers with medical insurers. Being out-of-network can actually be advantageous in many cases by giving your practice more flexibility, as long as you have a solid, opportunistic defensive playbook.
If your practice is out-of-network with the medical insurer, there is one critical term your practice needs to understand inside and out - clinical GAP exception.
A clinical GAP exception, otherwise referred to as an "in-network exception," is when there isn't a contracted provider within a certain mile radius on the patient's medical insurance policy. It is usually set at 25 to 30 miles. Most insurance carriers understand that it is not the fault of the member (patient) that the insurance carrier doesn't have a contracted provider close to the patient's home. With this understanding, many policies allow a one-time exception for a patient to see an out-of-network provider and use the in-network benefit level (deductible and coinsurance). This applies to both PPO and HMO plans. It still pays at the out-of-network allowable, so the dental practice doesn't get stuck with a lower in-network allowable.
Here is an example of why a practice wants to get a clinical GAP or an in-network exception.
Patient: Joe Sample (typical PPO plan) |
In-network benefits |
Deductible | Coinsurance |
$500 total | 80% insurance responsibility |
$300 met | 20% patient responsibility |
$200 remaining | |
Out-of-network benefits |
Deductible | Coinsurance |
$1,000 total | 60% insurance responsibility |
$0 met | 40% patient responsibility |
$1,000 remaining | |
In short, with a clinical GAP/in-network exception, the patient pays only $200 plus 20%. No GAP and the patient pays $1,000 and 40%.
READ MORE | Obstructive sleep apnea: How lifetime care can change everything
Getting a clinical GAP or in-network exception can sometimes be tough and take time, but the best billing services and dental practices know the importance of being diligent with this process. There are different ways to obtain it. Some insurance policies let the practice or billing service request it over the phone; some policies want supporting documents and SOAP notes (subjective, objective, assessment, and plan) from your software to be faxed to the utilization department; some require a medical doctor to submit an authorization request; and some state that the patient must call to initiate it. With the latter, it's recommended that a representative from the billing service or the practice do a three-way call with the patient to get it done promptly and efficiently.
Often, when calling insurance representatives for an in-network or clinical GAP exception, they won't recognize what you're requesting at first because it's not very common. The practice or billing service must stay patient and thoroughly explain the situation to the insurance representative until the person locates the policy in their system. This may take a 30-minute (or longer) phone call, and the whole process may take a couple of hours, but it's well worth the benefits of helping the patient, increasing reimbursement, or just getting coverage every time it's available.
This process also allows the dental practice to treat HMO patients who would normally have to be 100% cash patients. The same holds true for Tricare patients. When a dental practice also enrolls as a Medicare DME Supplier, the practice can market OSA services to the medical community and state that they accept all insurance, which is a great benefit for acquiring referrals.
Let the patient's insurance dictate the path of the sleep test referral
We'll start from square one with a patient who is screened and identified at the dental practice as potentially having OSA. The first order of business is to decide how that patient is going to get a sleep study. When it comes to sleep studies, the patient may have different options or paths to get the referral (if needed) and the study. For example, it is common for HMO policies to require a referral from the patient's primary care physician (PCP) in order to be eligible for reimbursement for the study. Also, the insurer may have specific guidelines for whether an in-lab sleep study or a home sleep test is considered medically necessary for that patient's condition. It is important to work closely with the medical community and your referral sources to ensure everyone has the patient's best interests in mind throughout the process.
When calling (or having your billing service call) and finding that a clinical GAP or in-network exception is available for the custom-made oral appliance (E0486), then using an in-network provider for the sleep study is in both the patient's and practice's best interest because the oral appliance will be billed in-network. Remember, the goal is to maximize reimbursement and reduce the patient's out-of-pocket cost, which in turn will help the practice convert more patients to treatment. Here's a brief example. If the patient has a $500 deductible in-network, and the sleep study and appliance is billed, then the patient is responsible only for the $500 deductible and probably 20% or less in coinsurance. Touchdown!
On the flip side, the patient is sent to an in-network sleep lab and pays the $500 deductible and the dental practice fails to inquire about the clinical GAP exception or in-network exception. The patient returns for the oral appliance, only to have $1,000 or more left on the out-of-network deductible the dental practice is billing against. This inconsistency costs the patient and dental practice over $1,000 in reimbursement based on the deductible and lower cost share on the coinsurance. It also impacted the patient because their out-of-pocket cost is now higher because they're paying a $500 deductible to the sleep lab and a $1,000 deductible to the dental practice.
This is not good business for anyone! Even the most experienced practices can make this mistake if the time is not taken to review and understand a patient's benefits.
READ MORE | Sleep Apnea: A problem we can tackle
What if A Clinical GAP or in-network exception isn't available?
No problem. Most patient policies do allow for clinical GAP and in-network exceptions, and few dentists go in-network because of the low reimbursement, the restrictions of balance billing patients, and other contractual obligations. However, you will run into this on occasion.
So what do you do when a clinical GAP or in-network exception isn't available? Assuming the patient has out-of-network benefits, it's more cost effective when the sleep study and oral appliance are both billed out-of-network. Coordinate the sleep study to be done with an out-of-network sleep testing facility. When the patient returns for oral appliance therapy, the deductible will be reduced, and the out-of-pocket cost from the patient to the dental practice is less. The sleep study is sometimes the biggest hurdle and can open patients' eyes to the many health dangers of OSA, even when they thought they were just snoring. What can be better than helping save lives and relationships?
There may still be a good chunk of deductible left at times. We coach offices in case presentation for oral appliances using the $1,000 out-of-network deductible as an example, and we advise our clients to present the entire dental sleep medicine treatment plan when discussing the $1,000 deductible with patients. When you put all that together, it creates value and patients are more likely to consider the $1,000 down on the deductible and move forward with the treatment plan.
Summary of the steps
1. Call the patient's insurance carrier to find out if a clinical GAP or in-network exception is available.
2. Intelligently decide the path of the sleep study.
3. Obtain a copy of the qualifying sleep study.
4. Send over all documents needed for clinincal GAP/in-network exception approval (sleep study, written Rx from physician, your SOAP notes, etc.).
5. Get the approval and take impressions.
Remember to capitalize on everything that's available from medical insurance carriers to maximize your success. Final Peach Bowl score—TCU 42, Ole Miss 3.
Randy Curran, medical billing director at Nierman Practice Management, has dedicated the last eight years to various aspects of the sleep medicine industry and successfully navigating medical billing in dentistry. His passion lies in helping dental practices understand medical benefits and the importance of medical reimbursement protocols. With this, he has helped many practices go from treating five OSA patients a month to as many as 40. Randy can be reached at 800-879-6468 or through www.DentalWriter.com.
