Medicare Decision Tree for Dentists

Do you see any Medicare eligible patients? If you are in the small minority of dentists who can answer “no” (primarily pediatric dentists who do not see disabled patients on Medicare), then you do not have to do anything about Medicare enrollment. Otherwise, please consider which Medicare enrollment step is most appropriate for you.shutterstock_161048585

Do you provide Medicare covered dental services? If you do not, there are two potential options to consider.

  •  If you write prescriptions for patients covered by Medicare and if refer out Medicare covered services to other providers, which most dentists do, consider enrolling in PECOS (Provider Enrollment, Chain, and Ownership System). By enrolling in PECOS, your Medicare patients can have coverage for the prescriptions that you write. Also, the Medicare providers who receive referrals from you (for a biopsy, for example) can also bill Medicare for Medicare-covered services. That is the extent of your involvement with Medicare with this option. PECOS enrollment is by far the most popular option for dentists.
  •  If you provide sleep apnea devices for Medicare patients and that is the only Medicare covered service you provide, consider enrolling as a durable medical equipment (DME) provider. When you enroll as a DME provider, you accept Medicare’s fees for sleep apnea devices. If you prefer to bill your full fee and have Medicare patients pay the difference between the full fee and what Medicare covers, consider enrolling as a non-participating Medicare provider who does not accept assignment (meaning Medicare pays the patient and not the practice). If you do not become a non-participating provider, and if you write prescriptions and refer out services as discussed in the first bullet point, you will also want to enroll in the PECOS system.

If you provide Medicare covered dental services, then you can consider enrolling as a participating or non-participating provider with Medicare. Non-participation status allows you to collect 9.25% more than you can as a participating provider since you can bill Medicare patients a little extra. However, if you want to attract more Medicare patients, you may have more appeal to patients as a participating provider (since it will cost them 9.25% less).shutterstock_185114144

Finally, if you provide Medicare covered dental services and you want nothing to do with Medicare, consider opting out of Medicare. This is the option, however, that creates the greatest amount of paperwork and record keeping for the practice. After you opt out of Medicare, you have to enter into private contracts with each Medicare patient before providing a Medicare covered service. There are guidelines regarding the language of the contract, namely that you and the patient are not allowed to send claims to Medicare for work done in your practice. In addition, you have to update the private contracts every two years. Finally, Medicare patients will not receive coverage for prescriptions you write.

In order to meet the June 1 and December 1, 2015 deadlines for Medicare enrollment, you need to take action now. After you enroll, it can take several months for approval, and you need Medicare approval prior to the deadlines. Please consider which enrollment path is most appropriate for you and get started today.

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