James Anderson

Unraveling Medicare Participation for Dentists

It may be one of the top three questions I get when a new office contracts for medical billing services. Should I participate in Medicare? Just like with any other insurance there is no easy answer for this – a majority of it depends on your patient demographics and location. If you’re located in San Francisco, CA the obvious answer would be “NO” – you probably don’t see a significant amount of retirees nor is anyone beating down your door looking for a Medicare dentist. Now take that same practice and relocate it to Fort Myers, FL…your demographic has shifted quite a bit and you may want to consider Medicare participation to keep your patient flow up.
For dentists there are three tiers for Medicare participation/non-participation and you should know all of them before opening up that can of worms.
Participating providers are exactly what they sound like. These are providers that have credentialed and signed par agreements with Medicare. You abide by the Medicare fee schedule and the patient pays you appropriate deductible and coinsurance amounts.
Non-participating providers are providers that are able to bill Medicare and receive assignment of benefits but receive a little boost to their allowables. These providers are able to charge 115% of the fee schedule fee. If you opt not to accept assignment your patients will need to pay in full for treatment and submit the CMS reimbursement form themselves – you will still be limited to the fee allowed.
Opt – out providers are providers who do not wish to enroll in Medicare and agree that their patients will also not be able to seek reimbursement. The patient will pay you out of pocket entirely with no funds going towards the deductible or out of pocket maximums.
Non – enrolled providers are providers who have done none of the above. They neither participate nor opt out. They are permitted to charge their UCR and patients can submit a claim on their own for reimbursement of what they pay the doctor.
The majority of providers who are enrolling in Medicare are doing so to help patients seeking sleep appliances or who do a large amount of reconstructive dental work following or preceding chemotherapy or radiation. Please keep in mind that should you decide to enroll in Medicare you will need to enroll in Part B with a DME add-on if you intend to do appliances or splints of any kind. As always it is best to try to work with an organization that specializes in Medicare credentialing. The application is long and complex at 30 pages and requires experience in credentialing providers properly.
There are always benefits to accepting commercial insurance plans. Most practices see an influx of patients and greater treatment acceptance. In the end only you can determine what is best for your practice and your patients.


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Dental Billing