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Dentists must choose to opt in or out of Medicare enrollment

June 16, 2014

By Kelly Soderlund

Any dentist who treats Medicare beneficiaries must either enroll in the program or opt out in order to prescribe medication to their qualifying patients with Part D drug plans, according to the federal government.

Either way, dentists who fit this requirement must take action by June 1, 2015. They either have to opt in or opt out.

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. By signing an affidavit opting out of the program, and entering into private contracts with patients as appropriate, dentists are out of Medicare for two years and cannot receive any direct or indirect Medicare payment for services provided to Medicare patients.  

CMS officials project that by requiring eligible providers to enroll, it will save the federal government an estimated $1.6 billion over the next 10 years.

"The policies finalized in this regulation will strengthen Medicare by providing better protections and improving health care quality for beneficiaries participating in Medicare health and drug plans," said Marilyn Tavenner, CMS administrator. "The final rule will give CMS new and enhanced tools in combating fraud and abuse in the Medicare Part D program so that we can continue to protect beneficiaries and taxpayers."

It's a change the ADA does not agree with and one Association leadership voiced their concern about in a March 5 letter. ADA President Charles Norman and Executive Director Kathleen O'Loughlin sent a letter to CMS asking that dentists be excluded from the requirement because it "places an unnecessary burden on dentists and their Medicare eligible patients," and it will not address the underlying rationale for a portion of the law, which is to stop fraud and abuse in the Medicare program.

In 2010, only an estimated 3-4 percent of the 186,000 practicing dentists were enrolled as Medicare providers, likely because the program only covers a limited set of dental procedures, most of which are recognized by CMS as necessary before the patient has certain covered medical procedures, Drs. Norman and O'Loughlin wrote in the letter.

"There is no reason to believe that the number of enrolled dentists has risen significantly because of the relative modest impact of the ordering and referring provision," the letter stated. "On the other hand, this new requirement will affect the majority of dental practices."

Despite the ADA's expressed concerns, CMS moved forward with the enrollment or opt-out requirement.

"Dentists who don't take action won't see an impact until next year but it will be when their local pharmacy or patient starts to complain that they are not being reimbursed for the prescriptions the dentist writes," said Dr. Andrew Vorrasi, chair of the Council on Dental Benefit Programs. "We're not sure how the pharmacies will handle this. Will they refuse to accept the prescription? Will they accept the prescription but force the patient to pay and tell them it's because Medicare won't reimburse the pharmacy or patient because their dentist didn't comply with the law? How will the patients react if they file their own claim for reimbursement that is denied? While the ADA opposed this action, it is one of those situations where the decision was beyond our control. Complying with this law will save practitioners much time and aggravation come June 15, 2015."

To read the ADA's Frequently Asked Questions on Medicare enrollment, visit ADA.org, click on the Member Center, then Member Benefits, then Legal Resources, Publications & Articles, Reimbursement, Medicare Enrollment Decision Tool: Introduction Medicare Enrollment, then Medicare Enrollment FAQ. The Reimbursement section can also take you to a Medicare enrollment decision tree and information on how to opt out of the Medicare program.