In Part 1 of this series, Dr. Todd Sander discussed their introduction to oral appliances for treating sleep disorders, highlighted alternatives to CPAP therapy, and his unique journey into dental sleep medicine integration.

Whether my new patient is coming to me for dentistry or dental sleep medicine, my initial examination is 90 minutes, preceded by 30 minutes with my clinical assistants to review their medical-dental histories, including the patient’s polysomnogram or home sleep test results; take digital or analog impressions; take radiographs or CBCT; and take photos and videos of the patient.

In my practice, I try to see dental sleep patients on Tuesday and Thursday afternoons. When an existing sleep medicine patient calls and is having an issue, we try to direct them to a block on a Tuesday or Thursday that is interchangeable with a restorative appointment. I prefer restorative procedures to be scheduled in the mornings and see emergencies and comprehensive new patients in the afternoons. I do not like to have other patients after I do a comprehensive exam with a new patient.

I have empowered my team to slide dental sleep medicine patients into our restorative schedule. Giving my team permission to do that and guiding them to understand that I want to provide both services was important. Otherwise, restorative dentistry would have filled my schedule and prevented me from working with sleep patients.

If an existing dental patient becomes a dental sleep medicine patient, I do a comprehensive sleep medicine exam, which is more like a medical exam. When my dental patients ask me if I’ll “just” make an appliance for them, I stick to my guns and explain that the documentation is different. I explain that we have now entered the world of medicine, and we cannot cut corners just because they have been a dental patient within the practice. So, on Tuesday and Thursday afternoons, I know I will likely have a new patient that’s a comprehensive dental patient or a dental sleep medicine patient.

We never want to tell a dental sleep medicine patient they will have to wait weeks to see me, so we might free up time on other days if slots are not filling up. This includes patients who are already within our dental practice. Many of our dental patients are referred for a dental sleep exam out of our hygiene department. Our hygienists are on board, looking at airways and helping guide patients who will benefit from OSA therapy. Part of your dental practice might be identifying airway issues as patients come through hygiene.

Scheduling may sound simple, but there is no easy button. Many of our colleagues who try to do dental sleep medicine become discouraged as they try to “fit this in” and treat it as just another appliance. So, I caution you. If you start working with dental sleep medicine patients, much more goes into the effort than delivering a simple dental appliance. It is the practice of medicine. The language and documentation that are required are medical in nature, and there is a lot to consider in treating and monitoring the patient, which I will discuss in future parts of this series.

Early in my career, I was introduced to oral appliances for treating OSA. While I was doing my residency in the Army, we saw patients with sleep disorders who couldn’t pass their flight physicals. Pilots were desperate for an alternative to CPAP because CPAP would ground them. Today, in my adult restorative practice, it’s clear that many patients benefit from an integrated approach to their oral health care and OSA therapy.

I started my private practice in Charleston, SC, in 2005. I was working with occlusal disorder and facial pain patients and several of them were non-compliant CPAP patients. One day, I was thumbing through my mail and noticed Dr. Henry Gremillion would be speaking at the Hinman Meeting on the connection between bruxism and sleep apnea. After hearing his presentation and reading the recommended literature, I thought sleep-disordered breathing may be at the root of many of my patients’ parafunction, evidenced by their persistent symptoms and the wear on their occlusal appliances. And it was this same population of patients who needed significant reconstructive restorative dentistry.

At the time, the American Academy of Dental Sleep Medicine was the only place where dental sleep medicine courses were available. So, I started with its introductory courses. It was clear that integrating dental sleep medicine into my practice protocols and educating my team and patients would take deliberate effort. There were questions I would have to address:

• How much time would I need to invest in training for myself and my team?
• How should I work sleep patients into my schedule?
• Which of the 32 FDA-approved appliances should I use? (Now, there are several hundred to choose from.)
• Should I invest in special software?
• Which medical providers could I work with, and how?
• How would I manage referrals?

My partner advised me to develop a vision and framework for my practice that would allow me to guide my team and focus my energies. I knew I would not be able to compete with others who were treating only sleep apnea patients. I decided that developing relationships with my patients would be as important for sleep dentistry as it is for restorative dentistry. And because I would also be dedicated to restorative dentistry, I would need to efficiently use my time to develop a niche practice in both restorative dentistry and dental sleep medicine.

With intentional forethought, my team learned how to screen interested patients and prequalify them for a comprehensive dental sleep medicine examination and consultation. I developed key people on my team to answer questions, gather the necessary information, and do preliminary work with incoming new sleep medicine patients. This preliminary work is much the same as that done by dental assistants in a restorative practice…reviewing the patient’s medical and dental history and taking digital impressions and X-rays.

When a comprehensive restorative patient comes to my practice, I do a 90-minute co-discovery examination, including sleep apnea screening. Then I take time in my lab doing diagnostic work with mounted models and plan treatment based on the radiographs, photographs, and other records we took during the comprehensive exam. The patient then returns for a consultation. If it is a complex restorative case, I spend time going over the treatment options, answering the patient’s questions, and developing my relationship with the patient. At this point, the patient is often ready to select treatment, and we move ahead with dental treatments. If the patient has the signs and symptoms of OSA, time is spent discussing the oral and systemic health benefits of having a sleep study and prescribed therapy. I refer my patient to sleep specialists I have developed a relationship with and know will provide a thorough evaluation. These specialists continue the OSA conversation and order a polysomnogram (sleep study) if deemed appropriate.

When a patient is referred to me by a physician to provide an oral appliance to replace CPAP or to be used in combination with CPAP, my comprehensive examination is a little different—with adaptations for medical documentation, but it is still 90 minutes. I have found that dental sleep medicine patients referred for sleep apnea treatment can usually be processed through their examination and treatment consultation in a single two-hour appointment. How I schedule my patients and the protocols I use will be discussed in future parts of this series.

When I speak with dentists who have dipped their toe in the waters of treating obstructive sleep apnea (OSA) in their practice, the number one reason they say they quit doing it or are not doing more is …

“I couldn’t get paid!”

You may be committed to helping patients achieve better health through treatment of OSA, but it’s challenging to make it financially possible. Here are three tips that will make dental billing for obstructive sleep apnea more consistent and predictable:

Use Practice Management Software to Simplify Dental Insurance

Understanding how to succeed in the complicated system of medical billing is a game-changer.

We have all figured out how to streamline our approach to making sense of dental insurance, but the rules are different for Dental Sleep Medicine (DSM). You should use a segment-specific software platform (DS3, NiermanDentalWriter, or other) for your SOAP notes and communication with physicians and payers.

These platforms ensure that you include the right notes, tests, patient status, and history to get paid. DSM and medical reimbursement are under the jurisdiction of rigid documentation of processes, protocols, and standard practices. Choosing the most effective DSM practice management software is the first step to payment because it will not let you forget to harness critical information.

Make It Easy for Patients to Say Yes to Treatment

My second piece of advice is the most difficult to implement because it requires a change in behavior. Talk less about co-payments, deductibles, and the patient’s responsibility than you may be used to in dentistry when dealing with obstructive sleep apnea.

As an example, consider this: When you visit your doctor and they suggest an x-ray, draw blood, or order a specific test, do you usually say, “How much will that cost?” No, you don’t. We know that tests and medical treatment recommended by our physician are necessary and not usually optional to achieve optimal health.

Plus, we know that their treatments will be covered by our medical insurance (after the deductible and with certain co-payments). As dentists, we are expected to have significant upfront financial discussions about how much the patient will have to pay out of pocket because of the different nature of dental insurance.

Unfortunately, this same approach when applied to a sleep apnea appointment may backfire. Treatment of sleep disorders can be life-changing, so it’s beneficial to the patient if you focus less on dollars and more on care outcomes.

When we get detailed about the financial arrangement, upfront copayments, and deductible discussion, patients think we are still treating them as a dentist, not as a medical care provider. Make it easy for patients to say yes by leaving out the money talk. Many will have good coverage and can make the treatment a possibility.

Outsource the Details to a Competent Billing Company

Hire a billing company to do the dirty work. Third-party billing companies (Four Pillar, Nierman, Pristine, Dedicated Sleep, GoGo, Brady) typically charge a small per claim fee around $50 and 8-12% of the paid amount. This fee is worth every penny.

I have seen far too many revolutions from the administrative teams in dental practices when they were forced to try to figure out the weird, ever-changing rules of insurance reimbursement.

Billing companies are experts. Plus, the cost as a percentage of sales works for medical practices, so why shouldn’t it for dentistry?

Treating patients for OSA with Oral Appliance Therapy (OAT) is easier clinically and technically than making bite splints in centric relation. And yet the minefield is littered with the remains of dental teams who tried to do the billing themselves.

If you only did one case per month, subscribed to a cloud software solution, paid a billing company their fair share, and risked not talking so much about money, you would still help patients get healthier, feel very fulfilled, and make more money than you are now.

That success can breed more success. You just might add $100,000 to your annual revenue! Curious how you can start incorporating treatment of sleep apnea into your practice workflow?

I’ll be holding a live, three-hour virtual course, “Treating Sleep Apnea In Your Practice With Oral Appliance Therapy,” on Friday, May 21st, 2021. Registration for my course is easy at Pankey Online.

Join me from 2 pm to 5 pm EST to learn more about the medical background of sleep conditions, marketing sleep appliance therapy, and more in-depth techniques I implement to transform medical billing.

Can’t wait to see you there!

Sign up for free at Pankey Online to access complementary and paid CE-granting webinars spanning hot dental topics like sleep apnea treatment, equilibration, and indirect bonded anterior restorations. 50+ cutting-edge courses at your fingertips …