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Thursday Troubleshooter: This dental practice opted out of Medicare. Any way back in?

May 5, 2016
This dental practice wants to know if they're required to wait several months to opt back in to Medicare. They're regretting their decision to opt out.

Do you have a tough issue in your dental office that you would like addressed? Each week the experts on Team Troubleshooter will tackle those issues and provide you with answers. Send questions to [email protected].

QUESTION: Our office has opted out of Medicare. Now we find out that the Medicare Advantage plans with dental benefits will not pay, and in addition, we have to write off the fees charged. We didn't know this when we opted out. We want to change to Ordering and Referring status. Our opt out ends in January 2017. Can we change before then, or are we stuck?

ANSWER FROM MARIA TATMAN, Terri Bradley Consulting:
Since the provider opt out isn’t due to be renewed until January 2017, you are unfortunately stuck until it comes time to renew your status. I realize this is a very difficult situation to be facing.

In the past, some dental teams that opted out of Medicare were allowed by the Medicare Advantage (dental) plan to submit dental claims for dental benefits even though the Centers for Medicare and Medicaid Services (CMS) rule stated otherwise. Some plans interpreted the rule differently than others, feeling that dental services are routinely excluded from Medicare coverage and could be billed to the dental portion of the plan, while other carriers said no, when you opt out you also opt out of Medicare Advantage Plans of all types.

It appears that this is changing. The only way to know for sure where you stand with each individual carrier is to contact them prior to a patient’s appointment to find out whether or not they will allow an opted out provider or the patient to submit their dental services.

The following questions and answers come from a FAQs that CMS recently updated. Here is the link if you would like to look at the entire document.

I realize this practice did not ask the following questions, but I thought they might be interested in the explanation Medicare provides. Many dental offices ask: If a dentist opts out of Medicare, can the office still participate in Medicare Advantage Plans?

Medicare payment cannot be made directly or indirectly for services furnished by an opt-out physician (including a dentist who opts out of Medicare), except for certain emergency and urgent care services. Therefore, no payment can be made under Medicare or under a Medicare Advantage Plan for the services furnished by an opt-out physician (or dentist).

This next question might seem irrelevant at first glance, but the answer addresses the concerns of many dentists: Do dentists need to be enrolled in Medicare?

Prescribers of Part D drugs must enroll in Medicare (or have a valid record of opting out). This includes Part D prescribing dentists. Please note: Dentists, including oral surgeons, will not be able to participate in a Medicare Advantage plan if they choose to opt out of Medicare. Upon submission of an opt-out affidavit, a provider has 90 days to change his or her opt-out status. After 90 days, a provider is not able to terminate the practice’s opt-out designation and will remain in an opt out status for a period of two years.

I hope this is helpful!

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