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Not opting in or out of Medicare hurts specialists, pathologists

August 18, 2014

By Kelly Soderlund

photo of Dr Arendt
Dr. Arendt
Dentists who treat Medicare patients who do not opt in or out of the federal program are putting the specialists and pathologists they refer cases to at risk of not being reimbursed.

Ask Dr. Douglas Arendt. The Vienna, Virginia, oral and maxillofacial pathologist is closing his practice Aug. 31 because he's taken a loss on so many cases he's processed for his referring dentists because they were not identified as Medicare providers. For specialists and pathologists to get paid for the covered services dentists provide to Medicare patients, the dentists must use the Provider Enrollment, Chain and Ownership System (PECOS) to enroll as Medicare Providers or as Medicare Ordering and Referring Providers or opt out of the program altogether.

Dr. Arendt said he's tried to educate the dentists he works with but many of them have not taken action on their Medicare status or are unaware they need to for him to be reimbursed for the pathology cases they send him. It leaves him in an ethical conundrum: either refuse to process the cases because he won't be reimbursed or process them for the good of the patient but be out the money.

For dentists who send him cases who are not enrolled through PECOS, Dr. Arendt said he will send them the paperwork to help them get enrolled but it doesn't always help.

"Even though the practitioners are now trying to get into the PECOS database, it can be very tedious and you need to make sure their staff follows through with the Medicare customer service reps," Dr. Arendt said. "Patience and persistence is a must. Feedback from some of the providers who did their due diligence stated it was very challenging, and at times confusing, as to what information was really needed."

It was those reasons why four years ago, the ADA vehemently opposed requiring dentists to enroll in PECOS if they were to be Medicare providers. In 2010, then-ADA President Ronald Tankersley and ADA Executive Director Kathleen O'Loughlin wrote separate letters to the Centers for Medicare & Medicaid Services and Kathleen Sebelius, former Secretary of the Department of Health and Human Services explaining why the ADA is opposed to the requirement.

The ADA believes the PECOS enrollment process is too complicated and time consuming for dentists and requires information that is irrelevant for dentists who just want to refer and order prescriptions, according to the letter.

Dr. Arendt wants all dentists to understand that the pathologists they work with will not be reimbursed if the dentist is not enrolled as a Medicare Provider or as a Medicare Ordering and Referring Provider.

"I'm not sure how much longer I could have sustained a negative balance in my practice," Dr. Arendt said. "You always have a war chest, but I was honestly very concerned."

For more information on how to enroll, visit the website.

The ADA has an online tool that helps members determine whether they should enroll in Medicare or opt out at the Association's Center for Professional Success website,