Thursday, July 16, 2015
The Centers for Medicare and Medicaid Services (CMS) published a final rule in May 2014 that requires all physicians and eligible professionals—including dentists—who prescribe Part D covered drugs either to be enrolled in order for prescriptions to be covered under Medicare or to opt-out.
CMS recently moved the enforcement date to formally notify Medicare to June 1, 2016. Though it feels like, “Whew, I have more time,” delaying your decision is not a good choice. CMS has said that if dentists delay, thus swamping them at the last minute, it will take several months to process the paperwork no matter the decision. This can dramatically impact the practice bottom line.
If Your Office Doesn’t Accept Medicare
If you think your office won’t be involved in these changes, think again. The reality is our country is aging. Beginning on Jan. 1, 2011, 10,000 people turn age 65 every day. This will continue every single day for the next 20 years.
What’s more, many lose their dental benefits with retirement and will be looking for coverage under medical policies for dental care including Medicare. Some dentists have signed contracts with dental insurance network providers stating they agree to bill Medicare first for services that meet a medical necessity.
Therefore, if the dentist doesn't make a decision on what to do about Medicare, this will be a mistake for the practice and can result in loss of patients—perhaps many patients.
Staying Up To Date with Medicare
There is a big problem with waiting until the last minute when CMS is swamped. If the dentist has filled out the correct forms, filed early enough and it has been processed on time, no problem. If a dentist files the right forms (a challenging task) but CMS doesn’t process them by June 1, 2016, there will not be coverage for prescriptions.
If a dentist registered for Medicare in the past, nothing else is needed, right? Not so fast, this may or may not be correct. If the dentist has previously filled an 855i application and received a Provider Transaction Access Number (PTAN) some work is needed to make sure the PTAN is active.
If the dentist has not submitted a claim to Medicare in 12 months, the PTAN will become inactive. Even if a claim was submitted in the past 12 months, every 2 years the dentist must revalidate with Medicare. Failure to do this will lead to an inactive status
Figuring out the best Medicare choice by searching through the CMS website can feel like you are swimming in peanut butter. Faced with navigating this bureaucratic quagmire often the choice becomes to do nothing.
In the past, a dentist did not have to declare their status unless they performed medical services such as sleep apnea, billing for CT scans, etc. Under the 2014 CMS rules, if the dentist does not formally declare, Medicare does not recognize the dentist as enrolled in the registry, therefore no coverage. Not making a decision is still a decision; it’s just not a good one.
Finding Your Way
The challenges of Medicare are multiple. Complete answers won’t be found on the CMS website. The first decision is positioning the practice not just for current realities but future success too. No one can tell any dentist their right way.
Where are you in the business cycle? Are you a new graduate? Have you been out of school 10-20 years? 30-40? How soon do you plan to sell your practice and/or retiring? Some dentists think they will retire and not make a decision at all. Yet how saleable is the average practice these days no matter how long the dentist has been practicing? The success of the past can often blind us to current and future realities.
The American Dental Association Health Policy Institute research shows dental spending in the United States began to slow in 2002 well before the Great Recession and went flat in 2008. With several years of post-Great Recession data, it is clear that dental spending is not rebounding and has, instead, very likely entered a new normal.
Low dentist busyness levels and decreased wait times indicate additional capacity is available in the dental care system. Evaluating and implementing new options will create a new definition of dentistry and success. A dentist’s Medicare enrollment choice should follow a practice positioning decision.
The Correct Forms
Do you need to file: Opt-out affidavit; Opt-out Private Contract; 855o application; 855i application; 855s application; 855B application 588 form and/or 460 form? You might need to file 1, 2 or 3 of these depending on your choice.
These forms came be found on the peanut butter CMS website but where and which one matches the right choice for an individual dentist? My DentalCodeology: What Every Dentist Needs to Know about Medicare NOW eBook was written to not only answer those questions, but to provide practices with guidance on making their Medicare choice, along with hyperlinks to the correct forms and case histories to make the ramifications of the choices real.
Don’t Delay
Opting out might be the right choice if a dentist does not want to participate as a Medicare provider and does not intend to submit claims to Medicare. Still, as an opted-out provider prescriptions ordered will still be paid.
Yet it also might not be the right choice. What if the dentist is planning on adding sleep apnea services, decided to purchase a CT scanner for implants, or has other plans for expanding services and technologies in the future?
Decisions are best made when looking at a larger picture. Taking no action is still a decision. Find the resources to make the best Medicare choices for your practice now and in the future.