Whether to opt in or out as a Medicare provider

By Greg Alterton, CDA Dental Benefit Plan Specialist

Note: The Medicare Part D enrollment deadline was extended again. Please see "Medicare Part D enrollment deadline now January 2019” for more details.

A requirement dentists need to keep in mind this year is the designation of their status with the Medicare program. CDA is receiving an increasing number of inquiries about what to consider when choosing your status. Conversations with the ADA and the Medicare administrator for California indicate that additional information, and reminders about the requirement, will be needed as the deadline nears. 

Regulations of the Centers for Medicare and Medicaid Services (CMS) require dentists who treat or refer Medicare enrollees or prescribe medication to Medicare patients through the Part D Medicare drug program to either enroll in Medicare as a provider, or opt out of enrollment by June 1.  

CDA is aware of services being marketed to dentists by private consultants and businesses to file opt-in or opt-out forms on dentists’ behalf. This service may cost a dentist hundreds, or perhaps thousands, of dollars depending on which option a dentist chooses. While CDA cannot comment on whether the value of these services justifies their cost, it is important for members to know as much as possible about the Medicare requirement prior to committing to an independent consultant service.

There are actually three options for providers: to opt in, opt out or enroll as a Medicare-ordering and -referring provider.

Opt In 

The opt-in option allows dentists who perform Medicare-covered services to be reimbursed by Medicare. With some 5 million California beneficiaries in the Medicare program, it’s likely that every dental practice in the state has some patients who are covered under Medicare. Dentists have probably learned that Medicare does not cover routine dental procedures. However, Medicare will cover certain procedures that have a corresponding medical code —mainly oral surgery, periodontal surgery and lab work, for example. If a dentist performs procedures that are benefits in the Medicare program, the opt-in would allow the dentist to be reimbursed for those procedures. Of course, Medicare fees for those procedures would have to be accepted. Medicare.gov provides a search capability to inquire what services are covered by the program.

The point is, there may be little reason for a general dentist to opt in to Medicare as a formal provider of services, unless their practice performs procedures that also are designated as medical.

Opt Out

The opt-out option lets the CMS know that dentists are choosing not to participate in Medicare, and that any services provided to a senior who is in the Medicare program will be provided through a private arrangement between the practice and the patient. The provider who opts out will not be able to submit claims to Medicare, even if a procedure is a covered benefit in Medicare. However, services ordered or referrals made for services that are performed by other providers (physicians, pharmacists) will be reimbursed if those services are prescribed by a dentist who has opted out. 

To opt out, a dentist must submit an affidavit to that effect to the Medicare administrator (Noridian, in California), and provide his or her patients who are covered by Medicare with a private contract specifying that payment for dental care will be paid by the patient and that the dentist will not be submitting a claim for the care to Medicare. ADA has provided samples of both the affidavit and the private contract on its website. Note that a member login to the site is required.

Ordering and Referring Provider

The third option is to enroll with Medicare as an ordering and referring provider. This is a kind of in-between status – neither in nor out. This status does not allow the provider to bill Medicare for services, but does put the provider into the Medicare system and eases the care and coverage for a Medicare patient when they are referred to another provider, such as an oral surgeon, who may be a provider who has opted in. Enrolling as an ordering and referring provider also allows pharmacists and labs to be reimbursed by Medicare for prescriptions and lab services, such as biopsy analyses, when ordered by the dentist. The advantage of this status over the opt-out status is that a provider who opts out will need to renew that opt-out status every two years. 

An ordering and referring provider may have up to five years to renew that status. CMS provides additional information about ordering and referring providers.

Doing Nothing 

What if a dentist chooses to do nothing – not opting in, opting out or enrolling as a referring provider? If you never expect to treat or write prescriptions for Medicare-covered patients, doing nothing by June 1 is an option. However, a couple of negative things may result. If one does nothing in regard to Medicare, and refers out for covered procedures, let’s say a biopsy to a lab, the lab would not be able to get reimbursed by Medicare if the biopsy came from a dentist who wasn’t opted in, opted out or enrolled as a referring provider. So it makes payment for services problematic down the line for the patient if the dentist does nothing. 

Another negative could result if a provider who for Medicare is off the grid and treats a Medicare beneficiary and bills that beneficiary for the treatment provided. If the patient files a claim on their own with Medicare, the provider could get a notice from a Medicare administrator stating the provider needs to enroll in the system.

CDA has received calls from dentists who have been sent such notices. We have communicated to the administrator that the provider is a dentist, that Medicare will never pay for what the dentist provided the patient and the administrator has agreed that the dentist doesn’t need to enroll in Medicare. But still, the provider who is off the books, so to speak, could continue to get these notices when patients submit their own claims to the Medicare administrator. This is one reason for the private agreement between the dentist and the patient, so the patient understands that the services to be provided are not covered by Medicare and that Medicare will not be billed for the services. 

What CMS has done with the opt-in or opt-out opportunity, and by including dentists in this, is enabled Medicare administrators to either pay dentists for covered medical care, or to recognize that the dentist has opted out and has the ability to enter into private arrangements with Medicare patients to pay for their own dental care. So, there is an advantage for a dentist who performs care that is covered under Medicare to opt in; while there is also an advantage to a dentist who may likely never provide care that is covered under Medicare to opt out.

Should you choose to opt out, the affidavit is to be sent to Noridian Healthcare Solutions, Provider Enrollment, P.O. Box 6770, Fargo, ND 58108-6774 (for Northern California, or ZIP code 58108-6775 for Southern California). You can also contact Noridian for additional information at 855.609.9960. In addition, Noridian maintains an “opt-out” site.

As CDA anticipates additional clarifying information from CMS, and additional guidance and help from ADA, we will provide that information to members when it becomes available.

CDA Practice Support has a new resource available on cda.org/practicesupport titled “Medicare Provider Options”.

Updated: 11/17/16