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Good morning,
I have two questions--
1. Our practice offers 4 different E0486 appliances for OSA, but of course the recommended appliance(s) will vary depending on the patient. For a recent patient with diagnosed OSA, we only recommended one of the appliances because she is a grinder and this appliance is the only option that we feel is durable enough to withstand the grinding and dual-function as an occlusal guard. We have only billed E0486 to medical insurance. The patient recently asked if--since this appliance was recommended since it can dual-function as an occlusal guard--if we could bill it to her dental plan using the d9940 code. I didn't think it could (or else I'm sure I would have seen/heard about doing that before) but want to be able to give the patient a confident answer.
2. Another patient received an E0486 appliance from our office in August. She has been in for a few follow-up visits and reports that the appliance makes her gag so she does not wear it. We have tried to adjust the acrylic in-office but she comes back saying it did not help with the gagging. She was wondering if we could take back the oral appliance and refund her what she paid and also reverse the payment from her medical insurance. Her plan is on a calendar year, so she is on new benefits. Even if we decided to take back the appliance from the patient and refund what she paid, she would still be responsible for the lab fee. This being said, what is the appropriate thing to do regarding medical insurance in situations like these? Are we supposed to notify insurance and see if they request back payment? Or, since the patient still got the appliance and had it for 6 months, can we keep the insurance payment to help cover the lab fees and such? Hopefully this makes sense! Just not sure what is considered the "right" thing to do as far as the insurance goes.
Thank you for your assistance.
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Rank: Administration
Joined: 11/21/2012(UTC)
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Hi SCD!
Great questions:
1) Dental insurance generally doesn't offer coverage for oral appliances for OSA, so in my humble opinion, billing the device to dental insurance under D9940 is a bit misleading (although D9940 does require a report, so if you explain in the report what it is and they decide to reimburse, then that is their decision). Basically - billing 2 different codes because 1 device serves 2 different function may be viewed as "double dipping" - basically: I wouldn't do it :)
2) Situations such as these certainly can get sticky. No you are not required to refund anything and return insurance reimbursement.....as this is a medical device to treat a medical condition (although some insurers will require that you have a protocol in place to deal with complaints on DME items, which it sounds like from what you described below you did address the complaints as best as possible). I like to put it like this: if a physician prescribed medication for blood pressure and it didn't work, would the physician refund the patient for the office visit and would the pharmacy refund on the pills? Nope! The physician would adjust the dosage, look at other medication options or treatment options, etc.
However, if you do decide to refund the patient amounts that were reimbursed by the medical insurer, then yes you should send a written notification to the medical insurer.
Hope this helps!
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Rank: Guest
Joined: 9/8/2012(UTC)
Posts: 16,068
Was thanked: 16 time(s) in 15 post(s)
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You are so helpful, Courtney. Thank you!
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