Three options for dealing with upcoming Medicare changes that will affect your practice


With thanks to my colleague Terri Bradley for this very timely and important information.

By Terri Bradley, Terri 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 when the patient goes to the pharmacy.

Dentists have the following options for official status in Medicare. Ignoring Medicare or 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 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 the patients requests (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 by Medicare are biopsies, removal of lesions, some TMJ services, sleep apnea appliances and a few others.

For services that you are not sure will be covered by Medicare, the use of an Advanced Beneficiary Notice (ABN) is required in order for you to be able to bill the patient after the claim has been processed by Medicare. Without a completed ABN, for services that are not statutorily excluded, you will not be able to collect from the patient. Yikes!   

Opt-Out status requires a written affidavit to be submitted to your local Medicare carrier stating 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; you are not bound by the Medicare fee schedule.

This status does require 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 a Medicare patient 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 have dental benefits available.

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 for services, you must be enrolled before the provider of the service gets paid. For example if you refer a patient to a laboratory for blood work, in order for the laboratory to get paid for their services, 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 requires 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 be enrolled as a participating provider to bill Medicare Part B for services associated with the appliance like evaluations, radiographs, etc.

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.

The topic of Medicare can be very confusing. We are here to help you with the decision making and application process. We are providing 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; if you wish to become a participating provider in Medicare we will help answer your questions.  

Contact us today for more information. Do not wait until next spring, your patients are counting on you.

Terri Bradley Consulting

(978) 697-8338