Getting a GAP Exception for Oral Appliances for Obstructive Sleep Apnea

By Peter Blais, RPSGT

A GAP exception, also known as a network deficiency, is a way for a patient to get in-network insurance benefits with an out-of-network provider. Because many dentists are not in-network with medical insurance providers, it’s important for both dentists and obstructive sleep apnea patients to be aware of the GAP exception option for oral appliances.

Obtaining a GAP exception is “a common goal with almost all of our providers,” says Stacey C. Layman, DDS, D-ABDSM, partner at GoGo Billing, a medical billing company for dentists based in Scottsdale, Ariz. She says GoGo Billing is successful in obtaining the exception about 90% of the time.

Obtaining a GAP exception can be a huge help to a patient when paying for his/her oral appliance. In-network benefits usually have a lower deductible and a higher coverage percentage than do out-of-network benefits. Also, in the case of patients in HMOs, it can mean the difference between having great insurance coverage for the oral appliance versus having no coverage at all and having the device become an out-of-pocket expense.

Layman

Layman says when GoGo Billing calls a medical insurance company for benefit verification, she also requests a preauthorization and a GAP exception at the same time. “This can take up to 45 days for approval,” she says.

Often, the medical insurance company’s initial response is to deny GAP because of an in-network provider in the area. But Layman says many times that in-network provider doesn’t actually provide oral appliances, contrary to what the insurance company might assume. “We actually call each provider just to make sure they do oral appliance therapy. Many times it is an oral surgeon that only does surgery, not appliances,” Layman says. “We then file an appeal and fight the denial. Depending on patients’ benefits, we will take it as far as possible to help patients get this life-saving treatment. If we are unsuccessful, we will help the office use patients’ out-of-network benefits.”

In an online forum, Courtney Snow, director of training, implementation, and software products at dental sleep medicine turnkey solution provider Nierman Practice Management in Sanger, Texas, provides an example of language used for a GAP exception request:

“There are no in-network providers within a reasonable distance to this patient who can provide this treatment/service/equipment. Please honor the patient’s in-network benefits to this out-of network provider on a one-time basis as a courtesy to your beneficiary to receive the medically necessary treatment they have been prescribed by their physician.”