Analyzing Your Practice Options

Christine Taxin

In my work with Links2Success, I help dental offices learn how to bill medical insurance for certain dental procedures. In the past, many dental offices simply ignored Medicare. However, this is no longer a viable option. By January 2019, every dentist in the nation must choose to either opt-out, become an authorized provider for prescriptions and referrals, become a participating provider, or become a non-participating provider. If you don’t choose an option and submit the appropriate forms to the government, continuing to treat Medicare-eligible patients could result in in serious legal trouble. My eBook, Dental Codeology: What Dentists Need to Know about Medicare NOW, contains an in-depth analysis of each option. Remember, doing nothing is not a choice.

What is Medicare?

Many people casually confuse Medicare, which covers older Americans and people with certain disabilities, with Medicaid, which provides health insurance to low-income Americans. One reason for this confusion is that some patients are covered by both Medicare and Medicaid. Before you choose your Medicare Provider Status, it helps to know a little about the basics of Medicare, which has several parts:

• Medicare Part A covers hospitalizations and associated procedures. Unless you regularly provide services in an inpatient environment, you’re probably not going to have to deal with Medicare Part A.

• Medicare Part B acts as traditional medical insurance, but only covers certain procedures. Like many other insurance plans, it includes out-of-pocket expenses and copays. If you plan to bill a procedure such as a cancer screening, imaging, or oral surgery through Medicare Part B, be sure to check if the procedure is covered.

• Medigap Insurance is a private insurance plan designed to help seniors pay for expenses not covered by Medicare Part B. Medigap may offer help with paying copays and deductibles; however, it does not typically cover dental care. Medigap plans vary from company to company. If a patient has Medicare Part B and Medigap, you must check the benefits from both plans when you’re calculating how much a patient will have to pay out of pocket for a procedure.

• Medicare Advantage plans, also known as Medicare Part C, are Medicare plans provided through private insurers. These plans are required to cover everything covered by Medicare Parts A and B, but may also include additional benefits. Patients may not use Medigap insurance with Medicare Advantage plans, but if they’ve recently switched plans, they may not understand this. Every Medicare Advantage plan is different, so be sure to check benefits ahead of the procedure.

• Medicare Part D covers drugs and may apply to some in-office procedures. Some Medicare Advantage plans include Part D coverage, while others require the purchase of additional coverages. People who have Medicare Part B coverage and Medigap coverage may have an additional plan for their drug coverage. Be sure to ask about all insurance types when preparing for a procedure, so that you can get your patients the best possible insurance coverage. To provide a covered prescription, you must be registered to Medicare.

Billing for Certain Procedures

In order to bill Medicare for certain covered procedures, you must first register as either a participating or non-participating provider. A participating provider is part of the Medicare network. These providers bill Medicare directly for procedures and are reimbursed by Medicare. A non-participating provider bills the patient, but the patient may be reimbursed by Medicare for part of the amount. Your office must have registered with Medi­care and received a Provider Transaction Access Number (PTAN) in order to bill Medicare for procedures. If you are billing Medicare for sleep apnea treatment, even if you do not want to wait for the payment, you must have a PTAN number to bill.

Coordination of Benefits

If a patient has Medicare and employer-provided insurance, follow Medicare’s official guidelines for assigning primary and secondary insurance. You’ll need some basic information about the provider of your patient’s insurance. Conditions such as kidney disease or disability may also affect which insurance is considered primary. Finally, if the dental work is the result of an accident, Medicare may not pay until the liability insurance that covered the accident pays. The rules on primary and secondary insurance are fairly clear, but ask your patients the right questions in order to assign priority correctly.

Learning About Billing

You can find more information about Medicare, covered procedures, and billing at Medicare.gov and CMS.gov. However, if you and your staff feel that the Medicare billing process is too complex and confusing, or if you can’t decide whether to become a participating or non-participating provider, you may need to hire consultants to provide additional training.

Billing Medicare for necessary procedures can be a great service to your older patients and a good source of revenue for your practice. It’s worth taking the time to learn the ins and outs, so you can help more patients get the treatment they need at a cost that they can afford.

About the Author

Christine Taxin is an Adjunct Professor at NYU Dental School and the founder and president of Links2Success, a practice management consulting company to the dental and medical fields. She has more than 25 years of experience as a practice management professional.