The big decision

Oct. 15, 2014
Until recently, Medicare and medical insurance in dentistry were optional choices.

BY Louis Malcmacher, DDS, MAGD

Until recently, Medicare and medical insurance in dentistry were optional choices. Did you know that the Centers for Medicare and Medicaid Services published a final rule in May that requires all physicians and eligible professionals, including dentists, who prescribe Part D-covered drugs to be enrolled in Medicare or opt out for those prescriptions to be covered under Part D? What this means is that any dentist who treats Medicare beneficiaries (any patient 65 years and older) must either enroll in the program or opt out for these patients to be reimbursed for their prescriptions that you write for them with Part D drug plans.

Dentists must take action by June 1, 2015, and either opt in or opt out of Medicare. With this deadline, it becomes a very real decision process that must be made now. This is a very important decision as the correct decision can really grow your practice and gain you new patients. The wrong decision will cost you time, money, prevent many elderly patients from even considering your practice, and cause these same patients to leave your practice immediately.

There are many common mistakes and misconceptions about Medicare by dental professionals because we have never had to deal with it. First of all, Medicare is not a welfare program like Medicaid. Medicare is a health insurance that is offered by the government to those 65 years and older. Do a search using your practice management system to see how many patients you have right now who are in this demographic. They will all tell you that they have Medicare.

Yes, I know there are dentists who say they will never be part of Medicare. I tell them that it's too late - Medicare already knows about you as a dental professional. How is that, you ask? Do you have an NPI number, which is the National Provider Identifier (NPI) number that dentists and all health-care providers are required to have under the HIPAA Administrative Simplification Standard? The NPI is a unique identification number for covered health-care providers. Covered health-care providers and all health plans and health-care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. All this information is coordinated with CMS - the Centers for Medicare and Medicaid Services.

Dentists need to make decisions now on Medicare that will affect the future of their practices - whether to do nothing, opt in, or opt out. They also need to understand the definitions and ramifications of each one of those terms because each has specific requirements in terms of applications, affidavits, and patient forms that need to be filled out and submitted. The worst decision you can make is no decision because then you'll be in no-man's-land.

Whether to opt in or opt out is very practice-specific, and there are also different applications and provider statuses to choose from. The consequences of opting into Medicare vary depending on which way you opt in and can include accepting a Medicare fee schedule. There are very limited dental procedures covered by Medicare, so this hardly affects most dental offices. The consequence of opting out initially includes much more in-office paperwork with Medicare patients. Either way, this requires having a well-trained team to handle these requirements. Education and training are the key to making the right decision and implementing it.

Depending on your decision, there is a confusing and tedious application process. No matter what you decide, the application process will take two to six months, and if the application is not correct, it will be delayed even more. You can see that June 1, 2015, will be here very quickly.

Another reason why the right decision is so important is that whatever you decide will either lock you in or lock you out for two years. You'd better make the decision a good one. 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 practice, we used the professionals at STATDDS to guide us and submit our application to make sure we didn't lose our patients who are 65 years and over.

As you can see, this is a career decision, a business decision, and also a very important practice and patient management decision. The right decision here can be a very powerful marketing tool and can help you retain and recruit many new patients to your practice.

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). You may contact him at 800-952-0521 or [email protected]. Go to to find information about live patient frontline myofascial pain training, frontline dental sleep medicine, bruxism and medical insurance, Botox and dermal fillers training; to download Dr. Malcmacher's resource list; or sign up for a free monthly e-newsletter.

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