Dental Sleep Medicine Insider

DENTAL SLEEPInsiderMEDICINE February 2015

TIGHTENINGTHE EMA DEVICEWith Dr. Gy Yatros The EMA by Myerson is fabricated bit loose. Naturally, that’s never hap- by several reputable dental labs in- pened using any of the labs I just men- cluding Keller, Dynaflex and others. It has been one of my old faith- tioned (wink, wink!). But fuls for years now because of even when that happens, its simplicity. It has a very low there is a simple tool you profile design which encourages can utilize to add reten- patient compliance while also tion and get more life out maximizing tongue space. Howev- of the EMA while also avoid- er, over time, the trays occasionally ing unnecessarily returning the device lose a bit of retention. Sometimes, to the lab. Check out this short video to they even come back from the lab a see how a pair of Hilliard Pliers can save you time and money….www.DentalSleepSolutions.com

We need an ad 1.877.95.SNORE

“Like most dentists, O ratleastIthoughtso.Thatwas capability are significant improvements from I am a creature of when Medicare decided that thecustomaryHerbstdevice. Thenewde- habit, and now anydevicedeliveredto manage vicealso eliminatestheconfusionregarding Uncle Sam was obstructivesleepapneahadto havea the direction in which to advance the screw telling me that I fixed permanent hinge. At that time, key hole for protrusion, as it is now in the therewasonly onedevicethat metthat same upward direction on both sides of thecould no longer use standard,andit madeonlyby3 labs! device. my devices of Whatwasthedevice? A Herbst®! choice” Patients become easily confused when they Like most dentists, I am a creature of hab- titrate on their own and don’t necessarily Dr. Kenneth Mogell, D.M.D it,andnowUncleSamwas tellingmethat advance the device symmetrically and Boca Raton, FL I could no longer use my devices of knowingpreciselyhowfara devicehad choice. Really, a clunky low tech Herbst; a been protruded was always an issue with device fresh out of the 80’s? Could it have the conventional Herbst devices. I’m sure been any worse? How were my patients we have all experienced the patient who goingto dealwiththoseobtrusiveugly returnsto theofficecomplainingofmuscle metal tubes? More importantly, was this pain,onlyto discovertheyhaveadvanced dreadfuldevice goingtoworkandman- one side more than the other. SomnoMed age the horrible symptoms of Obstructive has designed the Herbst Advance with a Sleep Apnea? visualcalibrationindicatorthat willtellyou exactlyhowfarthedevicehas beenad- Guess what?I waswrong! vancedfromits startpoint.Withit,asym- metryintitrationcanbea thing ofthepast. In the 2 years since the Medicare edict, I have delivered a couple hundred Herbst Change in a time-honored device like a devicesto mypatientsandthe clinical Herbst was inevitable. SomnoMed listened results havebeenbeyondmy expecta- to dentists practicing dental sleep medicine tions. Patients are generally accepting of andmademodifications thathavebeen thedeviceand Physiciansandsleeptech- game changing. Because of these enhance- nicians find them easy to advance during ments,IhavemadetheHerbstAdvance my titration PSG's. primarychoiceforanoraldeviceto manage my patient’s obstructive sleep apnea. Nonetheless, there were limitations with the traditional Herbst. These have now been addressed with SomnoMed’s new SomnoDent Herbst AdvanceTM. Shorter metal tubes and 8.0 mm of advancement



By Dr. Stacy Ochoa though the the return on invest- common issues I It’s happened to many of us. ment (ROI) has been outstanding, the experience with referrals I receive We’ve marketed our Dental financial outlay can be significant. So, where do from my radio ads; many of those patients are Sleep solutions to our pa- new sleep patients come from??? undiagnosed. As I said though, many of the tients of record. We’ve had My highest ROI has been from presentations people that come to these public seminars are brochures in the lobby. we’ve presented to the public, to prospective pa- seeking a CPAP alternative. We’ve screened almost all of tients. It’s really very simple, costs very little, and them. Hygiene has identified patients with the has produced anywhere from 2-4 OAT patients Consider this… On the high end, I have spent signs and symptoms of SDB & we’ve walked from each meeting. Contact local civic organiza- $100 for the room & 90 minutes of my time them through testing and when appropriate, tions such as the Elks Lodge, the Kiwanis Club or speaking to a group and answering questions. we’ve treated them with dental devices. Now, other groups. You can also take out a small ad in a This resulted in 4 new OAT patients. I’m making what do we do? The low-lying fruit has all been local newspaper. Promote the event as a FREE this dollar amount up for the sake of this con- picked and you’ve gotten a hankering for treating PRESENTATION about how readers can get ener- versation, but let’s say your fee is $2,500. Using more patients with OSA because, well, because it gy back, sleep better, and possibly get off of their this algorithm, I was able to dramatically im- is REWARDING in every way; it’s personally satis- much maligned (ALTHOUGH EFFECTIVE!) CPAP. prove 4 peoples’ quality of life and make $10k fying, it’s interesting, and it adds revenue to the Either organize the presentation to be held during with an investment of $100. Fine, even if you practice, BUT NOW WHAT? Where do new sleep one of the organizations’ regularly scheduled factor my time at (again, NOT a real number) patients come from??? meetings or book a room at the local library, a $500/hour, that’s small coffee shop, or other frequented, well- $10,000 total collections - $750 my time ($500 I’ve tried multiple different avenues. Billboards known meeting place. When doing this, consider x 1.5 hours)- $100 room rental = $9,150. That is didn’t do well for me. I’ve heard that others have your target demographic so DO NOT BOOK THE an extremely low cost of acquisition with a had more success. Maybe it was placement, CHAMPAGNE ROOM AT THE HOT NEW NIGHT- significant ROI. Dental Sleep Solutions provided maybe the messaging, I’m not quite sure but it CLUB!!! I’ve spent as much as $100 on a room and me with the Powerpoint so all I had to do was wasn’t a valuable allocation of my resources. I’ve as little as zilch in other situations. spend 10 minutes customizing it with my prac- made some TV appearances that worked well, tice info & I was set. I’m not suggesting this but those are few and far between. Radio ads Then, either an articulate, knowledgeable staff approach will work for everyone BUT it has have done very well for my practice and even member that believes in what we’re doing, you,or been successful in my hands and several of my another individual can present a 30-45 Power- colleagues have experienced similar results.www.DentalSleepSolutions.com point defining the problems inherent to sleep apnea, the importance of a medical diagnosis, and Contact Cindy Herbert at Dental Sleep your potential dental device solution. You’ll find Solutionsfora FREEcopyofthe that a significant number of attendees have al- ready been diagnosed and are present because Powerpoint presentation she sent to me. they are CPAP intolerant. This addresses one of [email protected] 877.95.SNORE

877.95.SNORE

RECAPTURINGTHE BITE facial on upper teeth and from the lingual on ten years. That’s 7-8 hours a night, for ade, or 3650 nights, or about lower teeth. hours. Her bite has not changed. N single angstrom. Locked in. Solid. Wh Fx biteschange? Baaaahumbug! Fy F And then there’s Samantha, a 50 som B executive who got her MRD and th week moved to Brazil. She came back By. Dr. Richard Drake As a result, upper teeth can move back, and years later, thanking me for her increas lower teeth can move forward. We know this; ergy level and joie de vivre. She, too, ha So…now, you’re making Mandibular Reposi- Dr. Alan Lowe from Canada has studies that her device every single night. Bite you tioning Devices (MRDs) for your patients who follow MRD-wearing patients for years. But together, Samantha…..YIKES! Can you have been diagnosed with sleep ap- wait, my device is hard acrylic, and it still fits, your back teeth touch? They’re not nea. They’re sleeping better, feeling better; how can this be? I’m not exactly sure, but ing? No. In fact, I could get my fat little they visit their doctor and the hospital less of- my bet is that the slow and steady force ten; they’re healthier and happier……but actually moves the acrylic and plastic as completely between her po you’re not……..because (insert expletive of well as the teeth. Pure conjecture on teeth. She was completely your choice here) their bite has changed a lit- my part though… WARE her bite had tle. changed. Her teeth ha So what tends to happen from long moved, but her condy All treatments have side effects and our term use of MRD wear, and is not sitting in the fossa; MRD’s are not immune. there anything we can do to slow slid down and left he Go back to high school for a it down or better yet prevent it? In open. moment. For me, the a nutshell: There you have it, the tw 70’s…..long hair, bell bottomed tremes. Everyone else w pants, Rhonda Lee…..and Mr. somewhere between. Anderson, the geeky Physics teacher, talking about force vec-  Maxillary teeth shift back Summary: tors. F=ma. Torque=rfsintheta. Themaxilla  Mandibular teeth shift forward is attached to the cranial base, and our MRD’s  Posterior open bites can develop AM Aligner or Morning Repositi anchor themselves to the teeth which then tongue retruding exercise, and hold the mandible in a slightly open and for- My partner, Dr. Gy Yatros, and I, have made push EVERY day, first thing in ward position. The patient falls asleep, and thousands of devices and followed some pa- the lower jaw wants to fall back, closing the tients for decades. We’ve read a few studies morning, until bite feels norm airway and starting the downward spiral of and learned a thing or ten along the way. A Helps to keep teeth from driftin negative physiologic events that surround hy- couple of patient experiences come to poxia. BUT our MRD doesn’t let this hap- mind. Eloise, an elderly sweet lady, swears she condyle in place. pen. As a result, presssure is placed from the has worn her EMA every single night for overwww.DentalSleepSolutions.com

G From the top secret vault at Dental Sleep Solutions, r a dec- 30,000 we now bring you Not one THE 10 MUST DO’S ho says regarding bites: mething he next 1. Every patient signs an Informed Consent. ck three sed en- 2. Speak to every patient and make them acutely aware that bites can change. ad worn ur teeth 3. Document their bites / teeth position BEFORE you start. u make 4. Every patient gets an AM Aligner or Morning Repostioner. touch- e finger 5. Every patient gets coached on how to use the AM Aligner, along with tongue osterior y UNA- retruding exercise and chin push. even 6. Document bites / changes at each follow up visit in DS3. had not yle was 7. Consider augmenting MRD therapy with PAP therapy for all patients but especially ; it had er bite for patients whose bites start to change. Also note that PAP has been shown to change bites. wo ex- will be 8. NEVER consider telling a patient NOT to wear his dental device unless he has PAP tioner, therapy to fall back on. d chin n the 9. Remember that it’s easier in most cases to keep bites from changing than it is to try mal. ng and and recapture them after they’ve changed. 10. Do everything you can to keep bites from changing, but if they do, don’t fret. It beats dying. You can recapture posterior open bites, as we did with Samantha. She stopped wearing her MRD, started PAP therapy, and we utilized a Morning Repositioner several times a day, com- bined with tongue retruding exercises and chin pushes. It took about four months, but we did get her posterior teeth back together.

LearningByDr.DeWittWilkersonis More Than WatchingBy Dr. Steve Carstensen If you are looking for re- dentists to treat their sleep disordered don’t maximize the impact of new skills wards in dentistry, there is breathing patients. At the Pankey Insti- all by yourself, so we include on the fac- nothing like treating sleep tute, the days are spent learning from ulty lab professionals who have been patients. People who thank Dr. John Remmers, the physician who involved since the beginning of oral ap- you for making their lives so discovered obstructive sleep apnea, pliancetherapy andexpert team trainers much better, for giving with lectures and hands on training so you know exactly how to lead your them energy, and for help- with dentists who have over 15 years team when you get home. We want you ing them have hope for a each treating patients like yours every to take action, to make a difference in long, fulfilling life are in our day. Dr. Gy Yatros, founder of Dental your community health, and to feel theoffices every day. Sleep Solutions, is there for you every value for the time you spent learning.If you treat sleep patients, you already know day. Even the evenings are used for less You will sit with your patients, workingthis. If you are curious about adding services formal story-telling to round out the hard to hold back your emotions as theyto serve your patients to this level, you have learning sessions and discuss what’s on share their success with you.lots of choices. Dental Sleep Solutions has your mind. Tuition for this four and a That’swhatPankeydoes. Findoutmorewonderful videos to watch and share with half day course also includes your ownyour team. You can attend excellent lectures custom made appliance, a remoldable at www.Pankey.org. Our next Sleepat a dental conference near you. professional temporary appliance, and Course startsApril24th.Or, you can get involved with hands-on learn- a personal sleep study so you are readying in a supportive community where partici- to share your own experience withpants work side-by-side with 7 experts from your patients and your team. You willmedicine, dentistry, and industry who will be ready to make a difference in theirprepare both novice and experienced sleep lives, and in your practice, right away. The Pankey Institute understands youwww.DentalSleepSolutions.com



“I love the A-Z concept. WHEN CE “I can honestly tell you, I wasIt gave me what I need IS SOOO actualy dreading this courseto fully implement.” MUCH MORE becauseIthoughtitwouldbeDr. Jorge Angulo so boring. I am so thankful I By Staci Holbrook came and feel completely“The course was ex- different about dental sleeptremely informative CE is ubiquitous. It’s online, medicineandlookforwardtoand user friendly, very in your mailbox, at the study addingitinourpractice.”practical information. club, EVERYWHERE! But, is KellyMcLaneAll speakers gave us a all CE created equal? Whenwealth of info that will was the last time you sat “When you sign up withhelp our office to move through a day long commer- DSS, you’re not just get-to the next level and cial masquerading as educa- ting a software package.build a future in dental tion? Equally as frustrating can be an over- You are joining a teamsleep medicine with ly academic course in which the content that provides tremen-DS3. Thanks to every- has ZERO real world application. dous knowledge andone at DS3 for your experience to help youhelp and instruction in Have you been to other Dental Sleep Med- treat your patients. Theygetting started. Cindy, icine courses, only to leave feeling a bit truly care about you andStaci, &Brandie gave us smarter but still not knowing how to de- your success. They willexcellent training and velop the info into a workable patient flow motivate, educate, train,helped us to get set up. that actually makes money for the prac- and encourage yourThe course offered eve- tice? team to succeed.”rything we needed andwe look forward to What do you want in a CE experience? Do “Wel presented and orga-working with DS3. you want an engaging speaker? An inter- nized! Best common senseThanks also to Jason for esting topic about a product or service andpertinentinfodeliveredinbeing so accommodat- that could make your practice more effi- asleepcoursefordentistsanding & tailoring the parts cient, improve patient outcomes, and gen- staff wanting to implementof the presentation to erate more production? Hands-on experi- dental sleep into their prac-meet our needs.” ence? Do you want your team involved to tice.”Sharon Camerino solidify their buy-in so you’re not met with Dr.DougJungmann the standard “Monday-after- the- course” resistance? I could wax poetic about the quality of Dental Sleep Solutions courses but I’ll just zip it & let some past course attendees tell you what they think. Read on and then CONTACT ME TODAY to register you and the team for an upcoming course. 1.877.95.SNORE [email protected]



MEMBERDSS Office Manager Contact Dr. Layman at www.GoGobilling.com or call 877-874-GoGo (4646) ext 2www.DentalSleepSolutions.com

1.877.95.SNORE

S o what is the answer? There are why take the gamble? cially posted on the Medicare websites for The options are as follows 1) Opt the E0486 code, however we have seen three options, and you get to choose one. out of Medicare 2) Become a par- allowables from A $1700.00, B $1321.61, Becoming a Medicare provider is a big C $1032.37 and D $1320.00. Medicare decision and can be daunting, but it is ticipating provider 3) Become a will pay 80% of the allowable, if the pa- something all dental offices will have to non-participating provider. tient, but if the patient has supplemental decide once they delve into the world of Let’s break each of these insurance they will pay the additional treating sleep apnea. Most ignore the big options down to simpler 20% up to the allowed amount and pay- looming question and figure they will terms. ments go to the provider. The upside is make a decision at some point. Let me tell The easiest thing case acceptance is 90% to 100% and you you why this is not the best strategy. to do is to “opt can start right away and not have to wait We all know the saying “we don’t know out” of Med- on a pre-authorization. what we don’t know” but in this case, not icare. Then Medicare non-participating provider; knowing won’t act as an excuse or de- you’re set for same set of rules but more money, Ya- fense to save you from Government fines two years. After hoo! The provider charges full fee and the and penalties. Dentists have never had to the two years are up, patient makes payment to the provider. deal with Medicare because dental work you need to opt out again Medicare pays 70% of the allowable, and has never been a covered benefit. Treating or choose to become a provid- supplemental will pay the additional 30%, a medical condition such as sleep apnea both payments being sent to the patient. with an oral appliance, IS a covered bene- er. In order to opt out of Medicare Case acceptance will go down but keep in fit and now you fall under the same guide- successfully, a signed ‘opt out affidavit’ is mind you can sign up as a non- lines as medical providers. Did you know mailed to your designated office. Once ap- participating provider and decide on a that treating a patient who is covered un- proved, Medicare will mail a letter to keep claim by claim basis to accept the assign- der Medicare, and having them pay for on file and it can be used as a denial to sub- ment or not. services and simply stating “sorry I don’t mit to any true secondary insurance plan. For more information and the complete take Medicare” is a federal offense? Yes When a patient presents for treatment, you guidelines for treating Medicare patients folks, it is! Not only could you be forced must formally inform them that you are not please email me and I will be happy to to pay the patient back, but you could be a Medicare provider and they will not re- send you the guidelines as well as a list of fined as well. The odds may be low, but ceive any benefit or reimbursement for a approved devices. GoGo also offers Medi- covered service. The patient must sign the care DME credentialing services for opt out patient contract and you keep it on 999.00 and for guidance in opting out I’ll file with their chart. No doubt that opting help…FOR FREE! out of Medicare comes with little hassle, but Stay tuned for my next article on Medi- is this the best decision for your practice? I care, Supplemental Vs Secondary. suggest you evaluate all your options before you turn your back on the old folks. Let’s Lesia Crawford, consider the other options Medicare has to CEO, GoGo Billing offer. 877-874-4646 ext. 1 Medicare participating provider; oh fun! [email protected] Lots a rules and not a lot of payment but you can feel good about helping your com- munity and the referring sleep doctors and physicians love it. Misery loves company, they say! “Participating” means you are willing to accept the allowed amount and not balance bill the patient over and above the said amount. There are four jurisdictions in the country and each has a different al- lowed amount. The allowables are not offi-www.DentalSleepSolutions.com

Why mess with faxing and keeping track of paper when you can scan it in once and forget it? DS3 Members receive $200 OFF one time registration fee!GoGo Billing is proud to be a part of the Using technology to bridge the gap www.GoGobilling.com between office and billing team, 877-874-GoGo (4646)Ds3 solutionfordentists. GoGo can now offer a simple and 8700 E Vista Bonita Dr. Scottsdale, AZ 85255GoGo nowhastheperfectbillingsolution seamless billing solution using DS3. Contact Lesia Crawford ext 1thanks to DS3's secure back office. Instead  Per Patient set up fee ...$40.00of fillingout super-bills,faxingsupporting  Benefit call.....................Includedinformation and emailing. Just request a  Pre-auth and GAP..........IncludedVOB(verification of benefits) with a click of a  Claim submission...........Includedbutton GoGo is notified and has access to  Appeals..........................Includedall the patient information to get to work.  % of claim payment ......9%GoGo nowhastheperfectbillingsolutionthanks to DS3's secure back office. Insteadof filling out super-bills, faxing supportinginformation and emailing. Just request aVOB(verification of benefits) with a click of abutton GoGo is notified and has access toall the patient information to get to work.

NEXT ISSUE: