Navigating Dental Sleep Medicine: Communication, Staffing, and Reimbursements

Written by
Aarogram Team
Published on
August 24, 2023

In the fourth installment of The Efficient Care Podcast, co-founder of Transform Dental Sleep, Jason Tierney brings a trove of unique skills, experiences and solutions that help sleep disorder patients find restful nights of sleep. He has spent nearly 20 years developing products, and business solutions for the fields of Dental Sleep Medicine and TMD. He has engineered innovative oral appliance designs, served as editor in chief of multiple dental sleep industry publications, and coached teams that have trained thousands of dental practices.

His recent book titled 'Transform Dental Sleep' offers a wealth of information about running a successful practice- from redirecting one's focus to the soft skills practice managers need to managing employees, patients and payors to handling your revenue operation practices right.

Listen to the full episode here

Transcript of the full episode:

Shruti: Jason, you've given 20 years of your life to dental sleep medicine and TMJ treatment. Our listeners want to get to know you more. Tell us a bit about how you found your passion for dental sleep.

Jason: Thanks, Shruti. I'd spent about 20 years in dental sleep medicine, and it started out working at a large dental laboratory and a leadership role there. And to be totally candid with you, at first it was a job, and over time I found the opportunity to be so staggering and the field to be so intriguing that I made it my career.

So, I spent a lot of time at a large dental laboratory. Coaching teams, developing teams, developing new products, new processes and procedures, and eventually left there and joined a specialized EMR exclusively for dentists treating sleep apnea and worked there for several years doing much of the same, you know, developing teams, finding new market opportunities, seeking efficiencies in our processes. And, then I also spent a lot of time as editor in chief of couple different dental journals, and more recently, over the past, three or four years, I started, with my partner as a consulting firm called Transform Dental Sleep.

And we work with some companies that serve dentists in the sleep field. And, most recently I published a book called Transform Dental Sleep, which I believe is how you and I got connected.

Shruti: I recently read your book and I thought it was an excellent piece of writing on dental sleep practice management, and I recommend it highly to both old and new dental practice owners alike. I want to dive in straight into the deep end and ask about this interesting phenomenon occurring in dental sleep practices, which is -- why are so many dentists quick to screen for oral cancer, but not for sleep related issues? What's causing this trend?

Jason: Yes. Oral cancer is terrible. It's awful. But with that said, it affects a very tiny percentage- far less than 1% of the population, whereas obstructive sleep apnea affects about 25% of the adult population. And I think that the standard of care at dental practices has become that you should screen for oral cancer.

And even though several dental associations have suggested that dentists, even if they opt not to treat sleep apnea, should absolutely screen for it- though it hasn’t taken off. It hasn't become the standard of care yet. And I think the message about the importance of screening is going to have to be more consistent from some of these, governing bodies or professional organizations that drive dentist behaviours.

Shruti: Tell me more- why are dental sleep practices not quick to think about sleep? And what's stopping dental sleep practices from screening for sleep apnea or insomnia?  

Jason: Yeah. I think largely, the not screening for sleep apnea has to do with this- dentists just don't view it as being in their wheelhouse necessarily.

Most dentists think that they're focused solely on oral health.  And when we're talking about systemic health, we're talking about an increased risk of heart attack, an increased risk of stroke. I think many dentists think-'' I provide nice smiles and clean teeth'', but there's so much more than that. But again, until these governing bodies of these professional organizations really spell out 'this is exactly what you should be doing  and if you don't, you're practicing outside the standard of care'--unless that happens, I think many dentists will still just look  at dental sleep medicine as something that some of their outlying colleagues do, rather than the norm, the standard of care.  

Shruti: Does it complicate the way sleep dentists run their practices? If dental sleep practices decide to incorporate sleep medicine into their practice, does it complicate the processes at a dental practice?

Jason: Yes and no.  I'm going to start with no, because there are a lot of similarities just as the dental team is looking for evidence of carries, of bone loss, all of these things that they're looking at, or oral cancer, as we discussed earlier. Just as they're looking for these things and they're identifying these things and then having a discussion about what  the treatment pathway should be, with the patient, it's very similar in that way. So let's look for the similarities first. And then let's focus on the differences.

So, the differences are when treating dental sleep medicine patients, the practice is billing medical insurance, and they're accustomed to billing dental insurance, they are referring patients to a physician, whereas they're accustomed to referring patients to other specialists like an orthodontist or a periodontist.  

I mentioned medical insurance. The insurance pathway is quite a bit more convoluted than it is with dental insurance. So all of these things throw a little bit of friction into the gears. Having said that, there are many dentists that are wildly successful and have built hugely successful dental sleep practices. So I would say to that. Look at that and know that it can be done. And because it can be done, you can do it.

Shruti: Right, I believe that patients are at the heart of all medical practices, including sleep and dental sleep practices. So is revenue. And without a sustainable business, one can forget reaching out to patients and changing their lives. What are the biggest misconceptions around revenue generation and dental sleep that you've come across personally?

Jason: Well, like many things in the world these days, it falls into binaries- so either dentists think that you are going to make a zillion dollars and be wildly wealthy, or they think you can't make any money in this and it's just a waste of time and money.

And the reality is, it's certainly not the latter and it's probably not the former either. I mean, you can be very successful, but there's this one idea amongst some dentists that you should be treating sleep purely for altruistic purposes and while the altruistic purposes should be number one --ultimately it is a business.

You have to generate revenue and it must be profitable. So that probably shouldn't be number one. Probably can't be number one, right? That's not enough of a primary focus to keep a business growing and moving, but altruism, a care for the patient as number one. And you know, building a successful business is maybe number two or three, I think.

Makes total sense and then there's this other school of thought that, this is healthcare and there's a result of that. No one should make any money. And that's not a good thing. I mean, you can do good and, and make money as well. And I think that’s where the focus should be. Help as many people as you can, as effectively, as efficiently as possible, and make as much money as you can, doing it fairly, justly and ethically.

Shruti: Any words of wisdom on communicating with billing companies about reimbursements? Any dos and don'ts that you'd like to share with your dental sleep friends?

Jason: Sure. I would say dental sleep friends, I have a message for you and that is -- communication is key.  Billing companies are some billing companies better than others. Absolutely Right. They aren't all created equal, but they are all billing the same codes to the same companies, and oftentimes I think clinicians mistake.  The hoops and pitfalls of the insurance world with ineffectiveness of their billing companies, and that's not necessarily the case.

I mean, again, some are better than others, but what I've found is if you have a company that you can communicate with or your team can communicate with, and they're on the same page, They're keeping them updated about the status updates on a claim, you should probably hang on to that company.

But communication is key. Provide the billing company with the documentation that they need. Give them the records that they need so that they can do their job. And when the payer institute some ridiculous new guideline that they had never done before, your billing companies are not lying to you, they're not making it up because in most instances, they get paid a percentage of the collection, so they're incentivized to maximize.

The collections because the more that you get paid, the more they get paid. So, find a billing company that communicates effectively, that has some good reviews or maybe some good word of mouth recommendations from your colleagues. Give them the documentation that they need. Realize that they're really a defacto part of your team. Treat them with respect. Give them what they need. They'll give you what you need.

Shruti: What are some of the biggest operational challenges facing dental sleep medicine practices today, in your opinion? When you walk into a dental practice, imagine you're Gordon Ramsay and you're wanting to go fix the restaurant, how would you tackle it?

Jason: I would just start yelling at everyone, what is this? Yeah. A lot of it really stems from communication. I would say communication is number one and number two and these are closely related, is communication and then a practice framework. That ensures predictability and reproducibility of operational steps.

So, to be able to have a clear process on how to screen patients, if a patient screens positively at risk for sleep apnea, where do they go then? Who talks to them? What does that conversation sound like? How do you help the patient realize their disease, the repercussions of not treating it, what their various treatment options are, what it costs?

As per our previous questions, what all the other processes look like, like who comes in and takes dental impressions, how do they take a bite registration, the jaw positioning? Which devices do they use and when for which patients? What are the indications and contraindications?

These are all things that if you have a clear framework, you can set the standard and do things pretty much the right way every time. But again, so much of that starts with communication. So, you'll probably remember Shruti, in the book when I talk about Read the Room -- relating to people, understanding where they're coming from, advising them of their solutions and then delivering. So basically, saying what you'll do and doing what you say. And I'd say that's key to do this in a dental sleep practice where, I think in my experience, you run into some issues with implementing this though, is a lot of this is dependent on what's, often known as, soft skills.

And a lot of clinicians want a step by step, black and white process on how to incorporate a new process or a new procedure. And so much of this is dependent upon development of those communication skills, those soft skills, and those interpersonal relationship skills. And you must be open to working on that because it's different than clinical skills.

Shruti: Let's talk about staffing. There are dental sleep practices or medical practices that do staffing right. And there are practices who struggle with staffing.  What are they doing differently and what are the challenges with staffing in the dental sleep field, in today's landscape?

Jason: Yeah, the challenges are abundant and especially post covid, it's become increasingly challenging for practices to acquire and retain key staff members. The biggest difference between those two practices, those that struggle with staffing issues and those that do not, is those that function smoothly have a place that people want to work.

And that starts with leadership. That starts way up here, right? So that, where oftentimes, the owners, the practice owners possess. Those interpersonal relationship skills that I just talked about a moment ago. So, they're charismatic people that care about their team members, they make sure their team members know that they're cared about.

There was something that I mentioned in the book about the four E's and that was educate, equip, empower, and encourage. And that's something that those practices do. They give their team members the education that they need so they know what they're talking about. They equip them with the tools to do the job, the resources to do the job.

They empower them so they have autonomy to do what they need to do, and they're safe to make mistakes. And then lastly, they're encouraged. So, when they do things right, they're told 'great job'. And when they maybe don't do things right, they're told 'it's okay, it's not the end of the world. Let's talk about why you did it this way. Now here's what I would've done differently and here's what I expect that you'll do differently next time.' So that's where practices that do well with staffing, I think really they excel and those that don't, I mean, I could say, that one they're in absence of those things but, they're just kind of the office is in chaos oftentimes. And when a team member enters, they usually by their second day of working there, they're thinking. The only people that still like working there are the people that foment that chaos and they've been fomenting that chaos there for a decade. So they're really comfortable in, in the sludge and the mud that they live in every day.

Whereas those successful practices, when they have someone who's negative or not contributory to the goals of the practice, they treat it like cancer and they excise that cancer immediately because nothing kills morale on a team faster than a leader letting you know negative contributors stay on the team.

If you educate them and they're capable, competent contributors, they'll take that along with that empowerment that you've given them, and they'll really propel the practice forward.

You know, it's interesting to me how, in dental sleep practice, so many of the processes are managed by the team.  But still the dentist tries to save a few dollars on hiring a team member. They hire a C list player rather than an A list to save a couple dollars an hour. And, that's just such short-term thinking at the end of the day. Saving $2 an hour could cost you a billion dollars a year.

Shruti: There are some smaller dental practices and sleep practices that are also running on lesser man-power, they are small teams. They are not bigger practices with 20-50 people, there are maybe 10 people running the business. How does a business owner of such a business train their staff to communicate properly with their insurance companies? What all steps can they take to help their staff communicate better with insurance companies, because that's where the revenue is, right? That’s how you get reimbursed?

Jason: Sure. Again, I think it really starts with just viewing your billing that your third-party billing company as a partner in the practice. So, realizing that even if the information that they give you isn't what you want to hear necessarily, that it's not because they're opposed to you as an individual. It's not because they don't want to help you. It's because this is some new wrench that the insurance company threw into the gear. So, I think it starts with that as just some empathy and then asking them what else do you need from us? What other documentation can we provide you with?

Would you like to see us provide that additional documentation every time we submit a claim for that payer?  Basically, how can we help you? And not only will you get that information so that you can do your job better and potentially have less, hassle or obstacles in the future, but you'll also get some social credit from that billing company because they're going to look at that and go, '' ow that was really nice of Shruti to ask me how she could help us. Right? And it's doing those things that builds a rapport that really helps in the long run. And again, those are the softer skills, but they're key.

Shruti: So, you talked about simplifying processes and you talked about this inherent chaos that comes with business, right? So, how do we simplify the processes that happen every day in the workplace? Can you give me one such example, of how you could simplify one of the processes at medical practice?

Jason: Yeah, absolutely. I mean, something that happens in dental sleep practice is a practice decides to start screening patients.

They develop that process, work out some of the kinks in the process, and then after the patient screens positive, now you've talked to them about what the process looks like to get scanned and get a device, and now it's time to talk about the costs, how much is covered by insurance and how much will be out of pocket. Most practices have a fairly low case acceptance percentage. And what's different between those that have a low percentage and those that have a higher percentage really focus on those communication skills.  

So, in the book, Alicia Crawford had a section, a Wow section, words of Wisdom, where she walks through exactly how she discusses treatment with a patient and the cost associated with it, and it's really helping the patient understand why this is important to their health, what they could potentially lose in their life as a result if they opt not to go forward, what they can potentially gain in their life if they do opt to move forward. What the cost is and what that's relative to.

I'm a runner, right? And if you told me, you could for $2,000 do something to my ankle where I'll be able to ride a bike three miles per hour faster. I don't care. I don't ride a bike. Couldn't care less If you asked me for $5,000 you could do something to my ankle, which would make me run a mile per hour faster. I mean, I'm going to the bank right now. And so, it's helping to attach the treatment to the outcome or the potential outcome. And I just think that's the key.

And again, that's a soft skill and I feel bad that I keep coming back to that because there's so many hard clinical skills that are imperative. But no matter how good of a clinician you are, how adept you are as a clinician if you don't know how to help a patient realize the need for treatment, you're not going to get to practice those clinical skills that often.

So, figuring out how to have a consultation appointment with a patient where they realize the benefits of moving forward with treatment is key to their wellness and your practices.

Shruti: So what are the top three takeaways that you want your readers to remember from your book? Transform Your Dental Sleep, and I'm assuming here, everybody wants to read it.  I have, and I enjoyed it immensely.

Jason: Thank you. As for the top three takeaways, I would say are-- that you can do this. And you should do this. And how do you know that you can do this? Because others have done it before you. So it is possible. Any dentist that's out there that, or any clinician that's out there that might hear this and thinks, I don't know if I can do this, you absolutely can because others have.

Next is that once again, communication is key. It's key to getting your team on board. And managing these processes effectively and efficiently for you, it's key to getting physicians to refer more patients to you. It's key to interacting with your patients so that they understand the benefits of treatment and they opt to move forward.

And lastly, I would say that, having a structure is also imperative. So you might remember Shruti in the book, I talk about Go Deep, that acronym, so that's one framework. But I mentioned the Go Deep framework that I developed and that's one that ensures that at every step of the way from hiring new team members to firing new team members, from meeting with physicians to, meeting with patients, setting your key performance indicators and pivoting is warranted. All of that is covered in the book, and I would say that having that framework is key so that your processes and procedures are scalable across the organization.

Over the years, I've seen different companies come and go -- that sort of promise dentists that if you pay them a certain amount of money that they'll just make this whole thing seamless for you and there is no magic pill to a successful practice. There are some supplements that you can buy, that will supplement your practice, but there's no substitute for the work.

Shruti: At Aarogram, we believe that being efficient in your business as a healthcare provider also means providing more patient-centric care. Therefore, we ask this question to every guest on a podcast, what’s the most ridiculous way you've ever solved a workflow problem in a healthcare setting?

Jason- This has to do with altruism, although it may not seem like it. It's terminating a team member and I say that because there are oftentimes legacy team members, people that have been there a long time, and when the practice is changing, it's evolving but those team members are resistant to change. So they're constantly creating friction in the practice, it's slowing down progress. It's mucking up the gears, and if the owner can get the gusto to actually terminate that employee.

What you oftentimes find is that, all of a sudden, the practice takes off. Everyone in the practice is happier so whereas everyone was walking around in sort of a doer mood and just going about the day, going through the rote motions, doing their job. Suddenly everyone's asking, how 'Can I contribute more? What can I do differently? How can I help?' And suddenly the practice exceeds all of their KPIs (Key Performance Indicators).

As far as team morale goes-- it's off the charts. You get to continue moving on to better things. So it's a win-win.  aligned with one's purposes once in a while.  

Shruti: Absolutely, one must aligne with one's purposes once in a while. Thanks so much for being on the podcast, and I hope our listeners pick up your book and have a go at it. It was wonderful that you've could join me today. Yeah. Thank you, Jason.

Jason: Thank you so much, Shruti. I appreciate all the work that you're doing.

This podcast series is brought to you by Aarogram.