Here at Terri Bradley Consulting, we field questions from providers who are confused about their responsibility when it comes to Medicare’s new regulation surrounding Medicare Part D (prescription drugs). We would like to share a few Q&A’s on the subject to help you with your decisions.
Here are questions we’ve received from providers with concerns about Medicare and how they and their staff will be impacted. We hope you’ll find this look into what other practices are struggling with informative and helpful.
2. What if I don’t comply with the CMS regulation?
If you choose to do nothing and prescribe or refer patients for certain services, your patients and colleagues may not be paid for prescriptions or referred services that would have previously been covered by Medicare. This can create an awkward situation for you as a provider when patients ask why you’re not complying with Medicare’s regulations. Additionally, if you’ve done nothing to this point and have referred patients for laboratory, imaging, or durable medical equipment services, Medicare may not compensate the providers you referred to for covered services, even if they’re network providers.
It is our understanding that at a minimum, if the provider prescribes potentially covered medications, for those prescriptions to be considered for coverage the provider needs to enroll as an ordering/referring provider with Medicare. Also, if the provider orders and refers other services such as laboratory, imaging, or DMEPOS services, and the referring provider isn’t enrolled at a minimum to order and refer services, those potentially covered services will be denied.
3. What does Medicare cover?
Medicare Benefit Policy manual, Chapter 15, item 150 states that Medicare excludes “Items and services in connection with the care, treatment, filling, removal or replacement of teeth, or structures directly supporting the teeth are not covered.”
Here are some services that may be potentially covered by Medicare – reconstruction of jaw due to trauma, oral cancer biopsy, oral evaluation and/or radiographic images prior to heart valve or transplant surgery, Sleep Apnea Appliance (DMEPOS), TMD services (trauma/pathology), radiation shield (prior to radiation), extractions (prior to radiation), and more.
4. How do I know whether to opt out of Medicare entirely or to be an ordering and referring provider only?
If a provider believes he or she will never provide a potentially covered Medicare service, it is suggested the person apply to be an ordering/referring provider only. This is to help patients and other providers that may be paid by Medicare to be properly reimbursed for those covered services, even if the originating office isn’t providing the service.
If you provide services that are potentially covered by Medicare (i.e., biopsies, TMD, traumatic injury, certain TMD or sleep apnea services, oral evaluation prior to radiation or transplant, etc.) and you don’t want to have to bill Medicare for those services, then you may want to consider opting out of Medicare. When you opt out of Medicare, neither you nor patients are allowed to bill Medicare or Medicare Advantage for services for a two-year period. You must fill out and file an official opt-out affidavit with the local Medicare carrier and enter into a private contract with the patients. The private contract is essentially an agreement between you and the patients disclosing that you have opted out of Medicare, their acknowledgment of that opt out, and the fact that Medicare will not be billed for the two-year opt-out period.
5. What is a private contract and how is it used?
A private contract is a signed agreement between you and the Medicare beneficiary. It is given to patients after you formally opt out of Medicare and prior to you providing a potentially covered service for a patient. It acts as a notification or reminder that a patient has been informed of the opt-out status of the provider, and that they are aware that the service(s) being provided will not be submitted to Medicare for reimbursement. You may have patients sign a private contract initially at the time you opt out, or you may furnish the contract to them when you provide the first potentially covered service. In addition, after an initial private contract has been signed, you must furnish a copy to patients as a reminder of your opt-out status when any future potentially covered service is provided.
6. Is there any reason I might want to enroll as a Medicare Part B provider?
Some offices choose to enroll as Medicare Part B providers if they are providing potentially covered services for patients that are Medicare beneficiaries. If you choose to enroll as a Medicare Part B provider and bill services for your Medicare eligible patients, you will be held to Medicare fees or limiting charges, depending on whether you enroll as a participating or non-participating provider. Only providers are able to truly determine what is right for them. Some office’s demographics are such that they feel it’s necessary to enroll in Medicare, while others may determine to opt out.
7. Can Medicare require me to enroll and bill services?
If you’re providing Medicare covered services now and you haven’t opted out or enrolled, Medicare can require you to enroll immediately and bill services Medicare would potentially cover for patients. Medicare can also require you to bill claims for services provided prior to your enrollment. If the services aren’t covered, Medicare can make you write off the services because a valid ABN (Advanced Beneficiary Notice) wasn’t presented prior to the treatment being rendered. (Refer to question No. 8 for details about the ABN.)
• For a five-part series of articles about Medicare, visit dentaleconomics.com and search for Medicare/Malcmacher.
8. What is an ABN?
The ABN (Advanced Beneficiary Notice) is a document used when you’re enrolled as a Medicare provider and you believe Medicare may not cover the recommended treatment based on it being unnecessary or not reasonable in a particular patient’s case. A valid ABN indicates to the patient and Medicare that you’re providing treatment for the patient that may not be covered by Medicare, and the patient is accepting responsibility for authorizing the provider to proceed with the treatment, and that they will be responsible for payment if Medicare determines the treatment provided unnecessary or not reasonable.
You’re required to furnish an ABN to the Medicare beneficiary before you provide the recommended treatment so a patient can make an informed decision about the treatment that Medicare may determine non-coverable. The ABN must be signed by the patient indicating he or she chooses to proceed with the treatment even though Medicare may not cover the procedure, and that they accept responsibility for payment. With a signed ABN on file the provider is permitted to charge the patient for treatment. If Medicare determines the ABN invalid or you don’t provide an ABN as necessary, you may not bill the patient and you may be financially liable if Medicare doesn’t pay. Medicare also states that ABNs may not be used for a component of care if that care is already part of a bundled service, or to transfer liability to the patient when Medicare would pay for the service.
9. What are my choices when it comes to Medicare?
You can enroll as a participating or non-participating provider in Medicare Part B. Some providers may be interested in enrolling because of patient demographics or as a service to their patients.
In addition to Medicare Part B enrollment some offices choose to become durable medical equipment suppliers. There is an additional enrollment process for DMEPOS. If you’re considering enrolling as a durable medical equipment supplier, you will need to consider Medicare Part B enrollment as well. You cannot be a DMEPOS provider and formally opt out of Medicare Part B.
You can formally opt out of Medicare. If you opt out of Medicare you will need to send an opt-out affidavit to the local Medicare carrier that covers your jurisdiction. The addresses can be found at www.cms.gov. You will need to notify the beneficiary of your opt-out status and enter into private contracts (refer to question No. 5) with the Medicare beneficiaries for any services that are potentially covered by Medicare or Medicare Advantage Plans. The opt out it valid for two years and can be renewed.
Enrolling as an ordering and referring provider only might be the right choice for you, if you believe you will not provide anyservices that are potentially covered by Medicare. It allows you to order and refer services for Medicare patients that you don’t provide and allows for coverage for prescriptions you write. You will not have to submit any claims or enter into any private contracts when choosing this option. Keep in mind, if there is a possibility that you will provide a service that is potentially covered by Medicare you may want to consider either opting out of Medicare or enrolling as a provider for Medicare. We mention this because if you choose to be an ordering/referring provider only, you’re telling Medicare that you don’t provide services they cover in your practice. If by chance you do provide a potentially covered service for a Medicare beneficiary and you haven’t opted out of Medicare, CMS can require you to enroll and bill those services on behalf of the patient. (Refer to questions Nos. 7 and 8.)
As you can see, the topic of Medicare brings many challenging decisions. We’re here to help you with the decision making and application process. We provide the following services to help you.
1. Guidance on the best option for your practice.
2. Completion and submission of the official opt-out affidavit along with a template for patient private contracts.
3. Enrollment as an ordering/referring provider in PECOS.
4. Enrollment as a Medicare Part B provider.
You can find additional information at TerriBradleConsulting.comunder the Medicare tab. You may also contact us at [email protected]. Don’t delay because the deadline for application is June 1, 2015!
Resources – www.cms.gov and www.palmettogba.gov
