New Medicare regulations require any dentist who provides covered services, or refers patients for covered services, to enroll either as a participating or non-participating provider. Failure to comply with these enrollment requirements will result in rejection of patients’ claims. This includes claims for Medicare covered treatments (such as biopsies or treatments for infection and trauma), claims for referred services such as lab work, and prescriptions.
If you answer “yes” to any of the following questions, evaluate your enrollment options below:
Do you ever write prescriptions for patients age 65 or older?
Do you ever perform biopsies on Medicare patients?
Do you ever order lab work for Medicare patients?
Paperwork should be completed and filed as soon as possible in order to allow adequate processing time prior to the enforcement deadline of June 1, 2016.
Enrollment paperwork must be completed separately for each dentist in the practice.
Option 1: Enroll As Ordering/Referral Provider.
This option allows dentists to continue writing prescriptions and ordering or referring for tests or additional treatment. Care provided to patients outside the dental practice as a result of those actions would still be covered by Medicare. This status does not require or allow the dental practice to file claims with Medicare. If you want to receive reimbursement for Medicare covered services provided in your practice, consider option two.
Option 2: Enroll As Part B Provider.
Practices that want to receive Medicare reimbursement for covered procedures should enroll as Part B providers. This enrollment does not affect services excluded from Medicare such as routine dental procedures. Services covered by Medicare, such as biopsies, will be paid at Medicare allowable fees. Providers file claims and Medicare rules apply to all covered services and claims filed. Prescriptions and referred services will still be covered, as allowed.
Option 3: Opt-Out Of Medicare Program.
Dentists who opt out may enter into private contracts for Medicare covered services. The patient pays treatment fees up front and no claims are filed either by the office or by the patient. Dentists charge the full fee and are not subject to Medicare fee schedules. Opting out applies only to procedures that are potentially Medicare covered services. This does not affect any procedure considered to be statutorily non-covered or excluded, such as routine dental work. If you opt out, covered benefits such as prescriptions and lab work will be paid directly to the provider, as long as an active Medicare provider provides them. DME providers cannot choose to opt out or their DME status will be nullified.
Option 4: No Action (Do Not Enroll Or Opt Out).
Providers who did not answer “yes” to any of the questions above, and never expect to treat or write prescriptions for Medicare covered patients are not required to enroll or opt out of Medicare. Pediatric dentists, for example, may fall into this category and may choose whether or not to enroll.
If you need further assistance selecting the appropriate option for your practice, ask your Henry Schein representative for a copy of our Medicare Guide for Dental Professionals. More information is also available at www.cms.gov.