LORI WALLACE
MEDICARE DO’S & DON’TS
ne of the most frequently
O
asked questions I receive on
a daily basis pertains to Medicare, the “dreaded” insurance
company.
There are specific rules, guidelines and standards that need
to be adhered to in order to
submit claims to Medicare. Actually, it’s a great idea to apply
these same standards to all insurance companies with the
exception of a couple. What
are these standards? Well, I’m
glad you asked.
1. Face-to-Face clinical evaluation with the treating physician prior to the sleep test
being ordered. This is not necessary for commercial insurance companies.
2. The patient’s AHI is equal to
or greater than 5 and less than
14 with documentation of any
of the following comorbidities:
Excessive Daytime Sleepiness,
impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease or
a history of stroke.
7. It is also imperative that
you obtain an ABN (Advanced
Beneficiary Notice of Noncoverage).
3. The patients AHI or RDI is
greater than 30 and the patient is not able to tolerate
PAP or the treating physician
determines that use of PAP is
contraindicated.
There are additional forms
that you need to have on hand
in your office as well. Your 3rd
party billing service can assist
you in obtaining those forms.
4. The device is ordered by
the treating physician following review of the sleep test.
You need to obtain a Letter of
Medical Necessity (LOMN/Rx)
from an MD for commercial
insurance companies.
Please do not hesitate to contact me if you have any additional questions. I look forward to hearing from you…
5. The device is provided and
billed for by a licensed dentist.
6. The device must be a
PDAC-approved device such
as a TAP or Herbst. A comprehensive list of Medicare approved devices can be located
in SNOOZLE.
For further questions, contact your third party biller,
or feel free to call me at (941)251-0393.
You can also email me at [email protected].
LORI WALLACE
Insurance and Member
Support Specialist