by Louis Malcmacher, DDS, MAGD
Dentists must take action by June 1, 2015, and either opt in or opt out of Medicare. This article is part three of a five-part series by Dr. Malcmacher on this topic.
Part I, October: The Big Decision
Part II, November: Opting Out of Medicare
Part III, December: Opting In to Medicare
Part IV, January: Time To Make A Decision
Part V, February: Types of Medicare
In previous columns, we described the big decision your office must make regarding Medicare, the various types of Medicare, and the opt-out option that may or may not be an appropriate choice for your office.
Let's take a look at one of the options for opting in to Medicare. There are actually a couple of options regarding opting in to Medicare, but first it is important to describe which dental services Medicare will pay for. Much of it is related to patients who are covered by Part A Medicare, which relates to hospital-based services or services associated with disease or trauma.
What Medicare will pay for
Section 1862 (a)(12) of the Social Security Act states, "Where such expenses are for services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth, except that payment may be made under part A in the case of inpatient hospital services in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services."
Medicare will reimburse dentists for dental services that are an integral part either of a covered procedure, such as reconstruction of the jaw following accidental injury or disease, or that are for extractions done in preparation for radiation treatment for neoplastic diseases that involve the upper or lower jaws.
Medicare will also reimburse dentists for oral examinations, but not treatment, preceding kidney transplantation or heart valve replacement, under specific circumstances. These oral examinations would be covered under Part A if performed by a dentist on the hospital's staff or under Part B if performed by a dentist after these diseases have been diagnosed by a physician.
What Medicare doesn't pay for
Medicare will not reimburse the following two main categories of dental services:
• A primary service (regardless of cause or complexity) provided for the care, treatment, removal, or replacement of teeth or structures directly supporting teeth. This includes preparation of the mouth for dentures and removal of diseased teeth in an infected jaw.
• A secondary service that is related to the teeth or structures directly supporting the teeth unless it is incident to and an integral part of a covered primary service that is necessary to treat a nondental condition (e.g., tumor removal) and it is performed at the same time as the covered primary service and by the same physician/dentist. In those cases in which these requirements are met and the secondary services are covered, Medicare does not make payment for the cost of dental appliances, such as dentures, even though the covered service resulted in the need for the teeth to be replaced, the cost of preparing the mouth for dentures, or the cost of directly repairing teeth or structures directly supporting teeth (e.g., alveolar process).
As you can see, Medicare Part B is very limited as to what it will reimburse when it comes to dental services. This now will be a key factor in deciding whether or not to opt in or opt out of Medicare.
Two options to opt in
There are two options for opting in to Medicare Part B. Either of these choices will fulfill the requirement for dental professionals to have a relationship with Medicare Part B so that their Medicare-eligible patients can be reimbursed for their prescriptions. To simplify this, I will call one option "opting in for billing" and the other "opting in for prescribing."
Opting in for billing requires the dentist to bill Medicare whenever the eligible services described above are rendered. If you have opted in for billing to Medicare and you provide an item or service that may be covered by Medicare, you must submit a claim on behalf of the Medicare beneficiary, and you are not allowed to charge the beneficiary more than the applicable Medicare limits on charges.
Dentists will also have to decide whether they want to be a participating or nonparticipating provider. This choice will result in different reimbursements for Medicare-eligible services. There are a number of requirements that need to be continually met, as well as knowledge regarding how to bill Medicare appropriately and with proper documentation. This opting option is most appropriate for dental professionals who are hospital-based or deliver many of these services routinely.
Opting in for prescribing was created for health-care practitioners who need a relationship with Medicare in order to be able to prescribe and order imaging services, clinical laboratory services, medications, and home health services. With this option, an opted-in provider can prescribe these services and Medicare will reimburse these services. The dentist or health-care practitioner does not have Medicare billing privileges and cannot submit claims to Medicare for any services performed on Medicare beneficiaries.
For most dental practices, opting in for prescribing is the preferred Medicare relationship as it will allow them to prescribe pharmaceuticals to patients, and Medicare-eligible patients can have their prescriptions reimbursed by Medicare when they pick them up at the pharmacy. The STATDDS Medicare enrollment specialists report that 90% of the Medicare applications they are processing for dentists are in this category.
Take action now
At this point, it should be well known that dentists must take action by June 1, 2015, and must either opt in or opt out of Medicare. The ADA, as well as many of its constituent societies, has been publicizing this to dental professionals. Like most people, dentists will try to wait until the last minute to make a decision or even to begin thinking about what to do concerning Medicare. This will be a mistake for many dental practices.
Depending on what you decide - whether it is opting in or opting out - there is an application process that is tedious, time consuming, and very confusing. The application process, no matter what you decide, will take two to six months, and if the application is not correct the first time, it will be delayed even more. You can see that June 1, 2015, will arrive very quickly. Many dentists will miss this deadline and will have a serious practice management problem on their hands.
There is no question that most dental practices should not go this alone. The choice of which direction, application, and provider status to choose requires careful evaluation, education, and professional assistance. For my own practice, we used the Medicare enrollment professionals at STATDDS to guide us and submit the applications for our dentists to make sure we make the June 1, 2015, deadline and that we don't lose our patients who are 65 years and over.
The Medicare choice for your dental practice is a very important decision because the right decision can really grow your practice and gain you many new patients. The wrong decision will cost you time, money, and many elderly patients. This decision needs to be based on practice management considerations that are unique to each doctor and practice. Making the right decision regarding Medicare is very important for your dental practice going forward, so make it the right choice.
Louis Malcmacher, DDS, MAGD, is a practicing general dentist and an internationally known lecturer and author. Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE) and serves as a consultant to STATDDS.com. You can contact him at 800-952-0521 or email [email protected]. Go to www.FacialEsthetics.org to find information about live patient Botox and dermal fillers training, frontline TMJ/orofacial pain training, frontline bruxism therapy, and dental sleep medicine, as well as Medicare and medical insurance information for every dental practice, and to sign up for a free monthly e-newsletter.
