Little-Known Ways to Pay for Oral Appliances

By Alyx Arnett

Oral appliance therapy has proven effective in reducing the severity of obstructive sleep apnea (OSA) in many patients, and it’s a treatment option with high adherence rates. One study found patients used oral appliances 6.5 hours per night, compared to 5.2 for CPAP.1 The findings support the hypothesis that oral appliances and CPAP yield comparable clinical outcomes due to higher compliance with oral appliances, resulting in comparable reductions in the apnea-hypopnea index, according to the study.

But cost barriers can present challenges to adherence, making it difficult for some patients to start therapy or replace damaged or uncomfortable devices. Dental sleep medicine practitioners and oral appliance device manufacturers share four common scenarios in which patients may need help paying for their oral appliance—and offer solutions. 

1. You Aren’t In Their Insurance Network

Becoming an in-network provider and navigating the intricacies of medical insurance and policy requirements are substantial hurdles for many dental sleep medicine practitioners.2 

“Payors don’t want to sign up new individual dentists,” says Matt Conlon, executive vice president of sales and marketing for North America at SomnoMed. “They can’t get direct contracts. It’s very, very difficult. Once in a while, they get lucky, but one of the major, major hurdles is that dentists have such a hard time getting direct contracts with payors.” 

The red tape can result in out-of-pocket costs for patients, despite having health insurance benefits, leading some to avoid the treatment altogether. For some, dentists might bill the payor on an “out-of-network” basis, leaving the patient uncertain of the cost until after the bill is submitted. 

These challenges recently led SomnoMed to partner with Nexus Dental Systems, which holds insurance contracts with major payors including Aetna, United Healthcare, Blue Cross, and Cigna. By working with Nexus for billing services, dentists can offer patients more predictable reimbursement, according to Conlon. “With Nexus, we want to build that patient access to affordable oral appliance therapy,” says Conlon. 

Other options can allow patients to receive treatment while paying over time. For example, Advanced Dental Sleep Treatment Center in Omaha, Neb, which is in-network with most medical insurance providers, accepts the CareCredit healthcare credit card and provides in-house, no-interest financing to assist patients. The latter offers terms of up to one year with a down payment. 

Jody Schmid, officer manager at the center, says determining the best option for patients often comes down to communication. “Have the discussion with them,” Schmid says. “You don’t know what people’s finances are unless you visit with them. Find out what they can afford, and then see if you can fit it into a program. It’s not always black and white.” 

Mark Murphy, DDS, DABDSM, lead clinical faculty for Prosomnus Sleep Technologies and owner of dental sleep practice Funktional Sleep in Rochester Hills, Mich, says, “A patient may qualify for CareCredit. A patient may easily have the means to pay over time. Some patients may easily have the means to pay all at once. And then there’s always going to be that patient who is really challenged financially, and that’s when any health care provider could decide or not decide to render that care.” 

2. ‘My Dog Ate My Oral Appliance’ 

Dogs are notorious for treating oral appliances as chew toys. Conlon experienced this firsthand with his first oral appliance. Treatment had been going well—he credited the device for stopping his snoring, allowing his wife back into the bedroom—but when his daughter’s dog visited, his oral appliance fell prey to its jaws.

That situation, in part, inspired SomnoMed’s three-year, no-questions-asked replacement plan for its Avant and Herbst Advance Elite products. The plan provides device replacement beyond the warranty terms, specifically for instances where dogs cause damage or other accidents, like the oral appliance falling into a garbage disposal, says Conlon. The damaged appliance just has to be returned to the manufacturer—so lost or stolen devices aren’t covered. 

Panthera Dental offers a 60-day, no-questions-asked remake at no cost, with a 50% remake after that, “ensuring peace of mind…for a positive customer experience,” says Marc Morisset, vice president of the sleep division at Panthera Dental. 

Kent Smith, DDS, DABDSM, CEO of Star Sleep and Wellness, with centers in Plano and Frisco, Texas, offers Dental Warranty, a nationwide protection plan—or what he calls “the dog insurance.” It safeguards against damage that falls outside the manufacturer’s warranty coverage (up to the full value coverage for dental treatments and appliances). Advanced Dental Sleep Treatment Center also offers Dental Warranty. “It’s been helpful because a lot of those people, if they didn’t spend the money and have that protection plan, they may very likely have gone untreated because of having to come up with the amount of money,” says Schmid. 

Some patients may not be aware that their oral appliance can be covered in their homeowners’ insurance with an addendum, says Murphy. “For a small fee a year, you could have coverage under the homeowners’ policy for the kind of loss we’re describing—fire, dog, flood, lost, stolen,” says Murphy. “It’s a good little factoid that dentists should be aware of so they can help their patients for a very low cost to protect those devices.”  

3. Device Fails After Warranty Period Ends

Two- and three-year manufacturer’s warranties are standard for oral appliances. But if a Medicare beneficiary’s oral appliance fails beyond the three-year window, it won’t be covered by the warranty, and Medicare won’t pay for a new one until the five-year mark.

To address this issue, Somnomed now provides a five-year warranty for its Pricing Data Analysis and Coding (PDAC)-verified Herbst Advance Elite for Medicare beneficiaries or payors following PDAC Medicare guidelines. “We want the dentist to not be on the hook, to be able to tell the patient, ‘I’ll take care of it for you. Somnomed will take care of it for you.’ We want them to be a hero to their patient, and the five-year makes sense because that’s the Medicare policy,” says Conlon. 

Prosomnus also considers this situation. The company’s standard warranty is three years, but coverage is extended to five years “where appropriate,” says Murphy, such as in situations with Medicare beneficiaries.

Other patients may need help paying for an oral appliance if they want a new appliance for reasons not covered by the warranty but aren’t yet eligible through insurance. For instance, Murphy says certain devices can “gunk up,” leading them to seek alternatives. Or, patients may question the effectiveness of a device or find it uncomfortable to wear. 

In such situations, in-house payment plans or credit lines can be beneficial. CareCredit, accepted at over 80% of dental practices, has become a “fantastic” option for dental patients facing out-of-pocket costs, according to Sameer Bhasin, vice president of dental at Synchrony, the parent company of CareCredit. “We pride ourselves on being the easiest and the quickest when it comes to giving the credit decision and trying to make it easy for not only the doctors and their team but also for the patients to apply, so they can get the treatment started soon if not immediately,” says Bhasin. 

4. Patient Wants Multiple Oral Appliances

Murphy has several patients each year who request additional devices. Patients may often want a second device—or third or fourth—to keep at their vacation home or for travel, for instance. An advantage of working with digital manufacturers, such as ProSomnus, is that creating another oral appliance is as simple as pressing a button. The patients’ scans and designs are stored digitally.

“It’s not like you have to send in a new impression. It’s not like you have to do a new design. It’s not like you have to have somebody new make it, so the cost of those second or third devices is significantly less to the dentist and therefore usually significantly less to the patient,” says Murphy. 

But Conlon notes the manufacturer may recommend new scans if enough time has passed. “Teeth can move and change. Maybe they had some dental work,” he says. “That’s kind of up to the dentist, but we encourage new scans depending on how long it’s been.” 

For patients wanting a second device who previously had an oral appliance billed on the Healthcare Common Procedure Coding System code E0486, an alternative code, K1027, can be used to bill for it. The code doesn’t require an inseparable hinge as code E0486 does. “If you go away from a PDAC appliance, you can use the ‘K’ code if you bill to United Healthcare, for example,” Smith says, noting that not all insurers pay well on code K1027. “But it’s just worth experimenting, and that landscape is going to be changing over the next year or two.”  

Murphy notes that Medicare beneficiaries wanting an oral appliance that’s not PDAC-approved must sign for it. “You have to provide a PDAC device, and then you can have the patient sign an ABN—advance beneficiary notice of non-coverage—and you can sell them a backup device that they know will not be covered by Medicare. But they have to sign that form,” says Murphy.

References

1. Basyuni S, Barabas M, Quinnell T. An update on mandibular advancement devices for the treatment of obstructive sleep apnoea hypopnoea syndrome. J Thorac Dis. 2018;10(Suppl 1):S48-56. 
2. Barrett JA. Commentary: the economic climate affecting the future of dental sleep medicine. J Dent Sleep Med. 2023 Jan 10;(10)1.

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