Navigating Medicare feels like being lost in a maze without a clue where to take the first step, we get it. Unfortunately, too many dentists have no idea that ignoring Medicare rules can really hurt them. Are you wondering what Medicare coverage has to do with your dental practice? Well, it’s more than you know.
If you treat patients over 65, or the growing pool of Medicare Advantage patients, you need to know about Medicare. You risk steep fines, limited power to help patients, and significant lost income if you disregard the rules.
Dental ClaimSupport has been helping dental offices since 2012 collect the most from insurance billing but also to correctly navigate the benefits for patients covered by Medicare. We’ve even written a book about it, with the help of Glenda Hood, author and professional coder with 30 years of experience in the field. It’s that important that dental professionals understand how these rules can apply to their billing process.
This article covers 5 essential aspects of Medicare for dentists. By understanding these subtopics of Medicare, your dental team won’t feel so lost when a patient enrolled in Medicare needs dental attention. We’ll show you where to take that first step toward smart Medicare decisions in order for your office to remain compliant and profitable.
Now let’s get into the 5 essential billing aspects of Medicare for dentists.
#1: Mandatory Filing law
The Mandatory Filing Law requires healthcare providers to submit claims for all services covered by Medicare. In other words, if you provide any Medicare-covered treatment to a Medicare patient, you're required to file a claim. Centers for Medicare & Medicaid Services (CMS) monitors compliance and health providers found in violation can be penalized.
You may ask - How would the CMS know you violated the law? Let’s say you have a patient covered under Medicare, and you then perform a biopsy procedure and bill the patient.
Because Medicare covers biopsies, your patient files a Medicare claim to pay your bill. If you're not enrolled as a Medicare provider, you cannot bill Medicare patients. And if you do, you’re in violation. When Medicare sees your bill, you could be the next dentist who gets a violation notice.
Medicare would send you a letter stating you are in violation and the penalty could cost you a fine up to $2,000 per incident.
But don't worry, you can avoid all this by making an informed decision. You have 3 choices:
- You can enroll in Medicare and be reimbursed.
- You can opt out of Medicare and not bill the patient.
- You can write up a private contract with the patient to pay your fee.
The point is, you have options that are a lot safer than ignoring Medicare and risking fines and sanctions.
#2: Ordering/referring requirement
If you have a Medicare patient who needs a lab test, you have to make a Medicare decision. You either have to enroll or opt-out of Medicare as an ordering/referring provider. Why is this so?
Think about this example. Let's assume you’re a dentist who is not enrolled in Medicare, and you perform a biopsy for a Medicare patient, free of charge according to the mandatory filing law.
You send the biopsy to a lab for testing. But you’ve not registered to either opt-in or out as a dentist with Medicare. So the lab can’t file a Medicare claim or bill the patient for the lab test. Your referral does the patient no good.
If you want to refer patients who have Medicare, any individual doctor either has to be opted in or out, which registers your personal NPI number and makes you eligible to order referrals for Medicare patients.
If you want to order outside tests or refer Medicare patients to specialists, you need to opt-in or out, so Medicare recognizes you.
That way your referrals will empower you to help your patients.
#3: Sleep Apnea Appliances
Providing sleep apnea appliances can be very profitable for your dental practice. Medicare recognizes sleep apnea as a medical condition and makes coverage available.
Even better, Medicare ONLY provides payment when the device – called durable medical equipment or DME - is provided and billed by a licensed dentist.
If you’re in a market where many patients need sleep apnea appliances, Medicare coverage can provide a healthy revenue stream for you. Why not expand your current services to provide devices only you as a dentist can supply, and help your own bottom line? Your Medicare knowledge can also expand your pool of patients in need of devices such as sleep apnea appliances.
#4: Provider enrollment options
You have to make decisions to opt-in or out of Medicare either as a provider, ordering/referring provider. Health care providers must enroll in the Medicare Program to get paid for providing covered services to Medicare patients.
Enrollment can be broken down into 3 options:
- Non-Participating provider
- Participating provider
- Ordering and referring provider
Think about how much Medicare-covered work you might do before deciding to opt out. As we mentioned before, it could provide a larger pool of patients and opportunities to generate more income.
#5: Medicare Advantage plans
You may have Medicare patients under 65 and not know it. Medicare advantage plans (or MA plans) are under the oversight of CMS, just like original medicare.
Put simply, most advantage plans provide some dental benefits.
A lot of dentists get caught off guard by unexpected denials from patients who have a MA Plan.
Many private insurance companies have contracts that allow them to offer Medicare coverage through a MA plan.
Some of those include:
- Aetna
- BCBS
- Humana
- Cigna
- AARP/United Healthcare
So, if your patients have MA plans, and you want to receive payment using their benefits, you’ll need to enroll as a Medicare provider. The growing numbers of working-age people with MA plans may be significant to your dental practice. So – think before you opt-out as a Medicare provider.
Ready to have full confidence in your Medicare compliance? An outsourced biller can help
You should now feel better prepared to face any Medicare billing issue that comes your way as a dental professional. You can now make well-informed decisions about whether to opt into being a Medicare provider for patients, and there are plenty of resources to help you along the way.
Dental ClaimSupport continues to train our professional expert billers on Medicare compliance, and they can help you if you’re still feeling confused on the subject. We also have on-demand training available, as well as our new book, Essential Guide to Medicare for Dentists, which dives even deeper into the topics discussed in this article.
To learn more about how outsourcing your billing can help you with Medicare billing at your dental practice, visit our Learning Center.
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