Have you made a decision on Medicare enrollment?
June 1, 2016 is the deadline for all the providers to either enroll or opt out of Medicare. Traditionally, most physicians, including dentists, have been enrolling in Medicare in order to provide covered services to Medicare eligible beneficiaries through the Medicare Part D plan or Medicare Advantage plan benefits. However, with the implementation of Section 6405 of the Affordable Care Act, physicians, including dentists, need to enroll in the Medicare program for the purpose of certifying or ordering services for Medicare eligible beneficiaries. These doctors do not provide actual services to Medicare eligible beneficiaries, but rather they write prescriptions for these patients that need to be covered when they go to the pharmacy.
The following categories of physicians must enroll in Medicare by the June 1, 2016 deadline:
• Physicians employed by the Department of Veteran’s Affairs;
• Physicians employed by the Public Health Service;
• Physicians employed by the Department of Defense Tricare Program;
• Physicians employed by the Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) or Critical Access Hospitals (CAHs);
• Physicians in a Fellowship;
• Dentists, including Oral Surgeons.
The biggest question that arises for all of the physicians, including dentists, if they have not enrolled in Medicare yet, should they enroll? How does one decide whether they should enroll or opt out of the enrollment by June 1, 2016?
Physicians, including dentists, have 3 options to choose from when making a decision with their status with Medicare:
1. Enroll as a Medicare provider;
2. Opt-out of the Medicare program;
3. Enroll as an ordering/referring provider.
Enrolling as a Medicare provider means that the physician/dentist will accept the Medicare fee schedule for all the services covered by Medicare. As a side note, a lot of the dental procedures in the dental office are not covered by Medicare.
Opting out as a Medicare provider means that the physician/dentist agrees not to bill Medicare for any service for a period of two years. This is an important decision, as the physician/dentist will have to formally let all of their patients know about their decision to opt out. This would mean that the physician/dentist, while not being bound by Medicare schedule, can bill the patients directly. However, should a claim be submitted by mistake on behalf of Medicare patient to Medicare, the physician’s/dentist’s status with Medicare may be jeopardized.
Enrolling as an ordering/referring provider means that the physician/dentist will not perform or bill for the services done at his/her office, but would be able to refer Medicare eligible beneficiaries to other facilities for services, as well as will be able to prescribe medications that would be covered by the Medicare Part D plan or Medicare Advantage plan.
The decision on whether to enroll in or opt out of the Medicare enrollment should be based on the following criteria:
• If a physician or a dentist already provides services covered by Medicare, then it’s easy for them to enroll in Medicare using form CMS-8551. In this case, they also have an option of formally opting out of Medicare all together.
• If a physician or a dentist does not currently provide services covered by Medicare, the next question they should ask is whether they order Medicare covered Clinical Laboratory Services (for example, sending biopsies to a pathology lab), Imaging Services, etc?
o If the answer to the above is yes, then they can enroll in Medicare using form CMS-8551. In this case, they also have an option of formally opting out of Medicare all together.
o If the answer to the above is no, they do not need to enroll in Medicare or formally opt out if they do not provide any services covered by Medicare or order/refer patients to covered clinical laboratory services.
One caveat that a physician/dentist should know is that if they choose to formally opt out of Medicare, or do not enroll in Medicare, as of February 1, 2017 any and all prescriptions this physician and/or dentist writes will not be paid for by Medicare Part D of the plan and/or Medicare Advantage plan for the Medicare eligible beneficiaries. Further, if a dentist opts out of Medicare, neither the dentist nor the patient will be able to submit a claim to Medicare Advantage plan.
Medicare has many complex regulations that can affect your practice greatly. The health law attorneys at Shapiro Law Group can work with you to determine the approach that suites you and your business best.
Anna Shapiro, Esq., LLM is a Chief Executive Officer at the Shapiro Law Group, who focuses her practice on health law, business and corporate law, family law, domestic relations and complex litigation. Anna may be reached at firstname.lastname@example.org.