Thursday Troubleshooter: Medicare – dental practices must make a decision

Gone are the days when dentists can tell patients they do not bill Medicare because it does cover dental-related services.

Medicare For Dentists

QUESTION: We have many elderly patients in our practice, most of them on Medicare. I’ve heard there are changes coming in the Medicare system in 2015 that will affect dentists, but have not heard much detail. As an office manager, I would like to find out more information to make sure I can help my provider and team prepare. What do I need to know?

ANSWER FROM TERRI BRADLEY, Terry Bradley Consulting:
As of June 1, 2015, all providers that write prescriptions for Medicare-eligible beneficiaries must be enrolled in the Medicare system through the Provider Enrollment Chain Ownership System (PECOS) in order for the Medicare beneficiary to obtain coverage for the prescriptions through the Medicare Part D Benefits.

What does this mean? Basically it means that all providers, including dentists, who treat Medicare beneficiaries and write prescriptions for these patients must have a formal status through Medicare, or the prescriptions will not be covered.

Dentists have the following options for official status in Medicare. Ignoring Medicare or making no decision is not an option.
1. Enroll as a Medicare provider
2. Opt out of the Medicare program
3. Enroll as an ordering/referring provider

If you enroll as a Medicare provider, you are required to accept the Medicare fee schedule as payment in full for services that are covered by Medicare. You are required to submit claims to Medicare for all covered services, and you must submit claims if your patients request this service (even if the service is not covered by Medicare). There are very few dental services that are covered by Medicare. Services that may be covered are biopsies, removal of lesions, some TMJ services, sleep apnea appliances, and a few others. If you are not sure what Medicare will cover, using an Advanced Beneficiary Notice (ABN) is required in order for you to be able to bill patients after Medicare has processed a claim. Without a completed ABN, you will not be able to collect from a patient for services that are not statutorily excluded. Yikes!

Opt-out status requires a written affidavit to be submitted to your local Medicare carrier stating that you agree not to bill Medicare for any services (covered or not) in a two-year period. You must also enter into a written private contract with each of your Medicare patients that states that they understand you are not a Medicare provider and they agree not to submit to Medicare for any services rendered by you. With this option you are allowed to bill your full fee to patients, and you are not bound by the Medicare fee schedule.

This status requires some upkeep in your office. The opt-out status expires every two years and the private contract must be completed for every patient. If by chance you treat Medicare patients and submit a claim on their behalf, your opt-out status could be jeopardized. Another consideration with opt-out status is the role of the Medicare Advantage plans as secondary payers. There are some Medicare Advantage plans that provide dental benefits. If you choose to opt out of Medicare, you are also opting out of Medicare Advantage plans, which means you cannot bill those plans either, even if they offer dental benefits.

Enroll as an ordering/referring provider only. You may choose this option if you do not perform any services in your office that are covered by Medicare. However, if you refer Medicare patients to other facilities, you must be enrolled before the service provider can be paid. For example, if you refer a patient to a lab for blood work, in order for the lab to get paid, you (the ordering/referring provider) have to be enrolled in the PECOS system.

Durable Medical Equipment Provider: Medicare does provide coverage for Oral Sleep Apnea appliances in some instances. The benefits are provided under the DME contract and require providers to enroll as a DME provider. A provider who has opted out of Medicare Part B, or who enrolled as an ordering/referring provider only, cannot enroll as a DME provider. They must enroll as a participating provider to bill Medicare Part B for services associated with the appliance, such as evaluations, radiographs, and more.

There is not one right answer for every practice. The choice you make will depend on the number of Medicare patients you have in your practice, the type of services you perform, and the overall make-up of your practice.

Medicare can be very confusing. We are here to help you with the decision making and application process. We are providing the following services to help you:

1. Guidance on the best option for your practice
2. Completion and submission of the opt-out option, along with private patient contracts
3. Enrollment as an ordering/referring provider in PECOS
4. Although we are not completing the Medicare enrollment package for you, we will answer questions if you want to become a participating provider in Medicare.

I wish you the best of luck, and commend you for taking a proactive approach to this important topic. I invite you to visit my website and subscribe to my newsletter, as this is an issue we will be addressing in the coming months.

ANSWER FROM MARIA TATMAN, Terri Bradley Consulting:
It’s good that you have Medicare on your radar, because many offices do not. Gone are the days when we tell our patients that the office does not bill Medicare because it does not cover dental-related services. As of May 2014, Medicare published a final rule that will take effect June 1, 2015. This rule will require all dentists, as well as other eligible practitioners who prescribe drugs covered under Medicare Part D, to opt out or enroll in Medicare for those drugs to be covered.

The June 16, 2014 ADA News stated, "Any dentist who treats Medicare beneficiaries must either enroll in the program or opt out in order to prescribe medication to their qualifying patients with Part D plans, according to the federal government."

Unfortunately, dentists are no longer able to put off making a decision regarding their relationship with Medicare. If you choose to do nothing your patients may be denied benefits at the pharmacy for their prescriptions. The reason behind this ruling is to help combat fraud and abuse in the Medicare Part D program.

What are your options?
You can opt out of Medicare entirely.
When doing so you must send an official opt-out affidavit to your local Medicare carrier. You must also let your patients know and enter into a written private contract with them. This is an agreement that will need to be renewed every two years. It means you and the patient are in agreement that neither of you will submit claims for services to Medicare during the opt-out period (two years).

You can enroll as a Medicare provider. If you have a high number of Medicare beneficiaries in your practice, you may want to enroll in Medicare. As a provider you are able to bill Medicare for those services that may be covered. If you decide to enroll, keep in mind that you’re limited to Medicare fees for the services provided.

You can enroll as an ordering and referring provider only. If you’re confident you don't provide any services that may be covered by Medicare (i.e., trauma, biopsies, sleep appliances, some TMD, oral exams prior to transplant or heart valve replacement, etc.), and/or you refer those services to other providers, this may be a good choice for you. This allows you to continue to order and refer services for the Medicare beneficiaries you treat, but you will not submit any claims to Medicare.

If you choose to do nothing you risk your patients being denied coverage for prescriptions as well as potentially covered services you refer to other providers, such as labs, radiologists, pathologists, etc. You also risk having to write off your own services. If you treat a patient who has Medicare for a traumatic injury or other potentially covered service, and you have not enrolled or opted out and the patient asks you to bill Medicare, you may be required by Medicare to enroll and bill the potentially covered services on the patient’s behalf. If Medicare determines no payment will be made, they can also require you to write the services off because you have no status with Medicare.

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Send your questions for the experts to answer. Responses will come from various consultants associated with Speaking Consulting Network, Academy of Dental Management Consultants, or Dental Consultant Connection. Their members will take turns fielding your questions on DentistryIQ, because they are very familiar with addressing the tough issues. Hey, it's their job.

Send your questions to All inquiries will be answered anonymously every Thursday here on DIQ.

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