Q&A: Top Medicare Questions

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In May 2014, Medicare released a ruling mandating that all prescriptions for Medicare beneficiaries must be written by a provider who is either enrolled in or has opted out of Medicare. Because of this ruling, dental practitioners are faced with making a decision on an unfamiliar topic. Since the ruling, there have been many consultants and publications attempting to assist dental practices in understanding Medicare and the regulations involved. Therefore, the issue is not a lack of information, but an abundance of information available, some of which is conflicting.

Some of the most frequently asked questions regarding Medicare concern:

The requirement for writing prescriptions.
Medicare benefits and coverage.
Medicare Advantage Plans.

The following answers are based on information readily available on Medicare websites and in Medicare Provider Manuals.

Writing Prescriptions

What is the new Medicare requirement?

Most dental practices are referring to the regulation regarding prescriptionswritten for Medicare beneficiaries. Centers for Medicare and Medicaid Services (CMS) Ruling 4159-F mandates that reimbursement will only be provided for drugs prescribed by a provider who is either enrolled in Medicare or has a valid opt out affidavit on file. This ruling applies to the Part D (prescription drug) program of both traditional Medicare and Medicare Advantage plans.

When will this new requirement be effective?

Implementation was originally scheduled for June 1, 2015 but was delayed. The current implementation date is June 1, 2016. CMS set a January 1, 2016 deadline for all enrollment applications or opt out affidavits to allow time for processing prior to the June 1, 2016 implementation date.

Does this requirement really apply to dentists?

Yes, this ruling applies to all providerswho are eligible to write prescriptions for Medicare beneficiaries. CMS and local Medicare Administrative Contractors (MACs) recently stated that dentists are included in this ruling. An article detailing this is the MLN Matters® article SE1305, which was most recently revised on September 24, 2015. This can be found at here.

Medicare excludes most routine dental procedures, so many dentists are not enrolled in Medicare. Accordingly, dental providers are eligible to enroll as an ordering/referring provider. This enrollment does not change the provider’s status with Medicare other than to allow the dentist to write prescriptions, order tests, and refer patients to specialists.

The requirement for writing prescriptions is part of an effort by Medicare to protect its beneficiaries and monitor the services provided. In January 2014, Medicare implemented a similar regulation requiring any provider who orders testing (e.g., pathology, laboratory testing, or radiology testing) to be either enrolled in or opted out of Medicare.

Will there be any transition time?

CMS is considering allowing pharmacists to fill a “provisional” prescription during a given time period following implementation. If this is allowed, the amount of time and/or the number of prescriptions provided will be limited. This potential grace period should not be used to postpone making a decision to enroll or opt out.

If I choose to opt out of the Medicare program, will the prescriptions I write be honored?

Yes, the ruling specifically states that those providers who have a valid opt out affidavit on file may write prescriptions. This also applies to any tests that may be ordered, such as a request for pathology testing or a referral to a specialist.

Can Medicare require me to enroll or opt out?

There is no mandate that requires a provider to enroll in Medicare. However, it is important to understand that there are laws that affect dentists and other providers. For example, those providers who choose to “do nothing” run the risk of having their Medicare patients’ prescriptions being rejected by the pharmacy. This could result in unhappy patients who may choose to seek care elsewhere.

I am a pediatric dentist. Do I still need to enroll or opt out?

Typically, pediatric dentists do not treat Medicare beneficiaries and, therefore, may not be affected by this requirement. Be aware that, while unusual, there are circumstances under which a child may be covered by Medicare.

Also, if the practice ever writes prescriptions for family members or friends who are patients who are eligible for Medicare, you may want to consider enrolling as an ordering/referring provider.

I do not accept Medicaid patients. Does this apply to me?

While CMS is the government agency that oversees both Medicaid and Medicare, this ruling applies only to Medicare and is unrelated to Medicaid services. Medicare applies to patients over the age of 65 and other specific individuals, including those who are disabled. Note that this ruling applies even if you do not provide Medicare covered services.

I have a large practice with multiple locations and several providers. Am I required to complete an enrollment application for each provider or can I enroll everyone working in the practice?

Each provider must complete his or her own individual enrollment application or opt out affidavit. If you are enrolling as a provider of services, it is also advisable to complete an application to enroll your practice as the billing entity.

Can some of my providers choose to enroll and others opt out?

Yes, this is an individual decision and each provider may choose to enroll or opt out. It is critical to communicate this to your team members so that they may provide your patients with accurate forms and information.

Coverage

What dental procedures are covered by Medicare?

Traditional Medicare specifies which dental procedures are covered. CMS states that, “Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw.” In addition, Medicare will pay for oral evaluations performed in the hospital as part of a comprehensive evaluation prior to transplant surgery. Medicare also allows payment for an examination performed in a rural health clinic (RHC) or a federally qualified health center (FQHC) prior to heart valve replacement. However, necessary dental treatment diagnosed during those evaluations will not be covered.

Medicare specifically excludes routine dental care, including dentures and all treatment in preparation for dentures. Furthermore, restorations, including dentures, are excluded even if the need for these services was precipitated by a covered procedure (e.g., restorations following cancer treatment or surgery).

The CMS statement on covered dental services can be found at here.

If dental procedures are not covered under Medicare, is there any reason I should enroll as a Part B provider?

This is a business decision based on the patient mix and the services provided in the practice. The only reason to enroll as a Medicare Part B provider is to be qualified to file claims with and receive reimbursement from Medicare. If you never perform any procedures covered by Medicare, enrolling as a Part B provider may not be necessary.

Keep in mind that many dentists, especially oral surgeons, provide services that may potentially be covered by Medicare. Examples of these services include, but are not limited to, the following:

Biopsies and excision of lesions.
Examinations and some treatments for temporomandibular joint dysfunction (TMJ).
Infections of the soft tissue.
Removal of dental implants due to infection.

If you perform and collect payment for any of these procedures, you are subject to the mandatory filing law, which has been in effect since September 1990. This law requires that physicians and suppliers submit claims for Medicare covered services provided to Medicare beneficiaries. The only way a provider can file these claims is to be enrolled with Medicare as a Part B provider. The penalty for noncompliance may carry a fine of up to $2,000 per violation.

Are there exceptions to the mandatory filing law?

Yes, when services are provided at no charge to the patient, there is no requirement to file a claim. Also, providers who have opted out of Medicare are neither required nor allowed to file claims except in life threatening or emergency situations.

Medicare Advantage Plans

Do I have to enroll in Medicare in order to file dental claims for Medicare Advantage plans?

The general answer to this question is no; filing dental claims to a Medicare Advantage plan does not require enrollment as a Medicare provider. It is important to understand that Medicare Advantage plans have many variations in their benefits. For example, an Advantage plan with dental benefits embedded in the medical policy may have enrollment requirements.

Keep in mind, however, that this is not the same as filing any medically related services. In order to file any medical claims to Medicare, whether a traditional plan or an Advantage plan, you must be enrolled as a Part B provider.

If I have opted out of Medicare, can I still file a dental claim for a Medicare Advantage plan?

Medicare funds cannot be paid to a provider who has opted out of Medicare. This includes Medicare Advantage plans. Some Medicare Advantage plans have dental benefits that are either embedded in the medical healthcare policy or administered under a separate dental policy. If a patient’s dental benefits are in any way a part of his Medicare Advantage plan, then benefits cannot be paid to the provider who has opted out. However, you may enter into a private contract with that patient. In this case, the patient becomes responsible for the fees in full.

How do I know if the patient’s Medicare is a Medicare Advantage plan?

Medicare Advantage ID cards are issued by the payer (i.e., BlueCross/BlueShield, Humana, or Aetna), and look very different from a traditional Medicare card. A traditional Medicare card is typically white with red and blue stripes at the top. Traditional Medicare patients may have a supplemental insurance plan. Typically, these supplemental plans are clearly described as either “supplemental” or “medi-gap.” While there are variations, most ID cards for Medicare Advantage plans will identify themselves. Medicare Advantage plans are not supplemental plans, but rather replace the traditional Medicare coverage.

How do I determine dental benefits for a Medicare Advantage plan?

Because there are so many variations in Medicare Advantage plans, the only way to determine benefits is to contact the provider services number listed on the patient’s ID card. While this can be time consuming, it is advisable to determine benefits prior to rendering treatment.

Note: Plans within each geographic location are usually similar. So, you should soon be able to create a database of the most common plans in your area.

My patient has a dental plan not associated with their Medicare. Can I file claims to that plan?

Many patients have stand-alone dental plans. Stand-alone plans are plans that the patient maintains as a retiree, either from an employer or plans they have purchased from an independent source. Any benefits provided by these plans are not related in any way to a patient’s Medicare coverage. Dentists may file claims to these payers regardless of their Medicare enrollment status.

Still Have Questions?

Medicare can be difficult to understand and navigate. The support team at Insurance Solutions Newsletter is available to assist our clients in answering questions and locating additional supportive resources. We can be contacted via email at support@ameridentibilling.com or by phone at +62 7000 4400.