Medicare and Dentistry October 29 2014, 0 Comments

(UPDATE: The Medicare Decision has been pushed forward until January 1st, 2016. This is still time sensitive)

The Big Decision

Medicare and medical insurance in dentistry for the last few years until now was an optional decision.  Did you know that The Centers for Medicare and Medicaid Services published a final rule in May that requires all physicians and eligible professionals—including dentists—who prescribe Part D covered drugs to be enrolled in Medicare or opt out for those prescriptions to be covered under Part D?  What this means is that any dentist who treats Medicare beneficiaries (which is any patient 65 years and older) must either enroll in the program or opt out in order for these patients to be reimbursed for their prescriptions that you write for them with Part D drug plans. 

Dentists must take action by June 1, 2015 and must either opt in or opt out of Medicare. With this deadline, it now becomes a very real decision process that has to be made now.  This is a very important decision as the right decision can really grow your practice and get you many more new patients.  The wrong decision will cost you time, money, prevent many elderly patients from ever considering your office, and will cause these same patients to leave your office right now.  

There are many common mistakes and misconceptions about Medicare by dental professionals because we have never had to deal with it.  First of all, Medicare is not a welfare program like Medicaid.  Medicare is a health insurance that is offered by the government to those 65 years and older.  Do a search using your practice management system to see how many patients you have right now that are in this demographic.  They will all tell you that they have Medicare.

Yes, I know that there are dentists that tell me that they will never be part of Medicare.  I tell them that it is too late - Medicare already knows about you as a dental professional.  How is that, you ask?  Do you have an NPI number?  That is the National Provider Identifier (NPI) number that dentists and all healthcare providers are required to have under the Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA.  All this information is coordinated with CMS – the Centers for Medicare and Medicaid Services. 

Dentists need to make some decisions now on Medicare that will affect the future of your practice - whether to do nothing, opt in or opt out.  You also need to understand the definitions and ramifications of what each one of those terms mean because each has specific requirements in terms of applications, affidavits, and patient forms that may need to be filled out and submitted.    The worst decision you can make is no decision because you will then be in no-man’s land.

The choice of whether to opt in or opt out is very practice specific and then there are different applications and provider status to choose from.  The consequences of opting in to Medicare vary depending on which way you opt in and can include accepting a Medicare fee schedule.  There are very limited dental procedures that Medicare covers so this hardly affects most dental offices.  The consequences of opting out include initially much more in-office paperwork with Medicare patients.  Either way, this does require having a well trained team to handle these requirements.  Education and training is the key to making the right decision and implementing it.

Depending on what you decide, there is an application process which is tedious and confusing.  Being that the application process no matter what you decide will take 2-6 months and if the application is not correct the first time, it will be delayed even more.  You can see that June 1, 2015 will be here very quickly.  One more reason why the right decision is so important – whatever you decide will either lock you in or lock you out for two years.  You better make the decision a good one.  There is no question that most dental practices should not go this alone.  The choice of which direction, application and provider status to choose requires careful evaluation, education, and professional assistance.  For my own practice, we used the professionals at STATDDS to guide us and submit our application now to make sure we don’t lose our patients who are 65 years and over.

As you can see, this is a career decision, a business decision, and also largely a very important practice and patient management decision.  The right decision here can also be a very powerful marketing tool and help you retain and recruit many new patients to your practice.

Louis Malcmacher DDS MAGD is a practicing general dentist and an internationally known lecturer and author.  Dr. Malcmacher is president of the American Academy of Facial Esthetics (AAFE).  You can contact him at 800 952-0521 or email   Go to where you can find information about live patient Frontline Myofascial Pain training, Frontline Dental Sleep Medicine, Bruxism and Medical Insurance, Botox and dermal fillers training, download his resource list, and sign up for a free monthly e-newsletter.