Dental Benefit Resources

Third Party Payer Advocacy

CMS Program Rule: Dentist Must Choose to Opt Out of or Enroll with Medicare

UPDATE - September 2016

To help you make the best decision for your practice, the ADA hosted a webinar that aimed to:

  • Discuss the basic differences between Medicaid and Medicare;
  • Highlight the three options available to you so that Medicare patients can receive drug coverage; and
  • Provide resources available to assist you in making an informed decision.

The webinar, along with other Medicare resources, is currently available for ADA/VDA members at the ADA Center for Professional Success.

Medicare Opt-in or Enroll Requirement

Over the past two years, dentists and their staffs have been seeking guidance regarding the regulations that require them to either opt-out of or enroll with Medicare and Medicare Advantage.  It has been a confusing process and sometimes difficult to find answers but the ADA and VDA have tried to be a helpful resource.  The deadline for taking action (either opting out or enrolling) has been extended several times and, as it now stands, the current deadline is January 1, 2019.  Below are some answers some of the frequently asked questions that the VDA has received from members.  We hope that you find this information helpful.

Frequently asked Questions

Do I have to do something (opt out/enroll) or can I do nothing?

If you do nothing, the patients for whom you prescribe any type of Medicare Part D drug with not be able to use their drug benefit.  All of those Medicare patients would be notified that you are not qualified to write them prescriptions.  Also, if you have patients with Medicare Advantage plans, you would not be able to bill for any of those services. 

What if I opted-out already and now I would like to change my status and enroll?

If you have already officially opted-out, your status cannot be changed for 2 years (unless you contact CMS within 90 days of opting out).  For those dentists who opted out before June 16, 2015, you must submit a renewal affidavit to all Medicare Contractors within 30 days after the current opted out period.  If you opted out after June 16, 2015, Medicare will automatically renew your status at the 2-year deadline.

How do I Opt-Out?

You must complete an opt-out affidavit form through Palmetto GBA*, which is the entity that administers Medicare in Virginia.  You can find the affidavit form by clicking here.    

*Providers located in the city of Alexandria and the counties of Arlington and Fairfax are considered part of the Washington, DC Metro area and therefore need to enroll and opt-out with Novitas, a different Medicare Administrator.  Click here for information on Novitas opt out and enrollment information.

How can I find my status and/or opt-out expiration? 

A list of Opt-out providers is accessible from Palmetto GBA online and can be found by clicking here.

Some other questions have been addressed by Palmetto GBA and can be found on their website here.

For additional FAQs, the Center for Medicare and Medicaid Services (CMS) has information on their website that you can refer to by clicking here.

Background: A final rule was published by the Centers for Medicaid and Medicare Services (CMS) in 2014 that requires practitioners who prescribe Part D covered drugs to be enrolled in Medicare or opt out for those prescriptions to be covered under Part D.  This means that neither the practitioner, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private contract is signed between the dentist and the beneficiary that states that neither one can receive payment from Medicare for the services that were performed. The practitioner must submit an affidavit to Medicare expressing his/her decision to opt out of the program.  Dentists are included with physicians and other practitioners who are permitted by statute to opt out of the Medicare program.

Medicare is administered by Palmetto GBA in the majority of Virginia and the opt-out affidavit can be found below.
http://www.palmettogba.com/Palmetto/Providers.Nsf/files/J11_Medicare_Opt-Out_Affidavit.pdf/$File/J11_Medicare_Opt-Out_Affidavit.pdf

Providers located in the city of Alexandria and the counties of Arlington and Fairfax are considered part of the Washington, DC Metro area and therefore need to enroll and opt-out with Novitas, a different Medicare Administrator.  The opt-out affidavit for Novitas can be found ​below.
http://www.novitas-solutions.com/webcenter/faces/oracle/webcenter/page/scopedMD/sad78b265_6797_4ed0_a02f_81627913bc78/Page57.jspx?contentId=00025018&_adf.ctrl-state=1cw4516y2u_4&_afrLoop=2729829151997000#!

If you do not wish to participate with Medicare but prescribe Medicare Part D prescriptions and would like for them to be covered for Medicare-eligible patients, this affidavit form must be completed and submitted to Palmetto GBA or Novitas.  By submitting a completed affidavit to opt out of the Medicare Program, prescriptions written by opted out providers will be covered by Medicare.  Any testing, such as pathology, will be paid to the laboratory providing the test.  A contract is only necessary when a dentist who has opted out of Medicare wants to provide a Medicare service to the patient and forego filing a Medicare claim (by signing the contract, the patient is agreeing to the dentist’s fee).  These contracts are not necessary for the patient to have Medicare Part D prescription coverage (patients will be covered as long as the dentist has opted out or enrolled with Medicare). The opt out period is valid for two years at which time the provider must choose to either renew the opt out or enroll.  Providers cannot choose to enroll during the opt out period.  

The ADA actively opposes this provision and is seeking an exemption for the dental profession.  Although the ADA immediately expressed their disagreement and concerns with the rule when it was first announced in May 2014, CMS moved forward with the enrollment or opt-out requirement. ​On January 13, VDA Executive Director, Dr. Terry Dickinson and ADA Executive Director, Dr. Kathleen O’Loughlin, met with CMS Administrator, Ms. Marilyn Tavenner and this issue was at the top of their agenda for discussion.  Further discussion between the ADA and CMS will occur and the VDA will be sure to keep members informed of the outcome.

Additional Information on Medicare Opt Out and Enroll Requirements:

Medicare Flow Chart

Medicare Advantage Question and Answer

Question: Do the Medicare Advantage regulations at 42 CFR 422.220 which specify that an MA plan cannot pay an "opt-out" provider  (except for emergency or urgently needed services) also apply to the supplemental benefits an MA plan offers?  For example, can a dentist who has opted-out of Medicare under § 1802(b), be paid by an MA plan for the supplementary dental services he or she furnishes an MA enrollee?

CMS Response:   A dentist that "opts-out" of Medicare cannot be paid for supplementary benefits offered by an MA plan (other than emergency or urgently needed services as defined in §422.2).  The Medicare requirement to not pay an opt-out provider at 42 CFR 422.220 applies to all services provided under or through an MA plan.  The definition of "physician" in §1861(r) includes doctors of dental medicine, so if a dentist has one of the affidavits under § 1802(b), the dentist can't be paid by the MA plan for services covered by the MA plan unless those services are emergency or urgently needed services.   

Opting-Out Information

The Enrollment Process
Contact Information for Medicare Administrators in Virginia
  • Palmetto GBA’s headquarters phone number: (803) 735-1034
  • Novitas’ provider inquiries phone number: 1-877-235-8073  (Alexandria and counties of Arlington and Fairfax)
Watch the ADA's video

Payers using credit/debit cards for payment

It is not uncommon today for dental benefit carriers and third party administrators (TPAs) to pay dental offices with a credit/debit card instead of the traditional paper check.  In fact, this trend seems to be more popular with TPAs than it is with traditional dental plan carriers and has created concerns for dental offices.

VPay is an example of a company that provides this service and offers a virtual stored-value debit card program designed specifically for claims payments.  VPay is delivered to the dental office either by fax or secure email. The dental office can process the payment just like it does any other credit card transaction – by entering the card number, security code, expiration date and amount.

VPay touts quicker reimbursement as an advantage to using the stored-value card; however, dentists have reported that the card may carry a higher processing fee than a traditional debit or credit card transaction.

You do not have to accept the stored-value card as payment if you do not wish to do so.  You can request to opt out of using the stored-value card and instead receive a check as payment for services rendered.  If that is your choice, you should call the toll-free number provided on the explanation of benefits (EOB) statement which accompanies the stored-value card and inform VPay or the issuing company that a check is preferred and that you are not interested in utilizing the stored-value card for claim payments.

The ADA has received reports from some dentists indicating that some of these companies’ customer service representatives are reluctant to waive the stored-value card as payment; thus, you may have to escalate your request to a supervisor or manager with the company.

The ADA’s Council on Dental Benefit Programs (CDBP) recommends dentists carefully read the fine print accompanying EOB statements and suggests that members call CDBP staff at 800-621-8099 for additional assistance. 

New Dental Benefit Resources from the ADA: Guidance on Coordination of Benefits and Signing Dental PPO Contracts

1.   Guidance on Coordination of Benefits

With the passage of the Affordable Care Act, more consumers are able to purchase dental plan coverage in their medical plans and additional questions have arisen with respect to coordination of benefits (COB). In 2014, the ADA House of Delegates passed Resolution 63H, which calls for ADA agencies to develop guidance on COB as it can be very confusing for both patients and dentists. The Council on Dental Benefit Program’s has drafted guidance and encourages member dentists and your appropriate staff to review the ADA Guidance on Coordination of Benefits. 

2.   Dental Benefit Educational Series

This is a new resource posted on the ADA Center for Professional Success (CPS). There are 3 tutorials so far.  More tutorials will be added on different issues. 

Signing the Contract: Understanding PPOs

This free video tutorial, Signing the Contract: Understanding PPOs will provide an overview of dental benefits market, and introduce common issues reported to us by contracted dentists.  The ADA understands the importance of how third party programs interface with dental offices and this information is provided to help you understand key issues. Click here to view this video.

 

ADA Position on Explanation of Benefits (EOB) Language
ADA (and VDA) staff frequently receives calls from dental offices regarding potentially misleading language on explanation of benefits statements sent to patients.  Dental and medical plans utilize the EOBs to notify beneficiaries of how an individual claim was processed for payment purposes. The EOB statement provides information such as dates of service, procedure codes, dentist’s fees, dental plan’s allowed amount and total payment.
 
One area of concern with EOB statements is the lack of consistency of the content between plans.  For example, some EOBs include a patient responsibility column and others do not. When a service is downcoded, or an alternate benefit is applied, the EOB should indicate the amount the dentist can bill the patient.  Thus the ADA created a model EOB template for consideration by dental plans.
 
Another area of concern is language that contains misleading and inaccurate statements such as “the treatment was medically unnecessary, experimental or cosmetic in nature.” ADA staff recently received notice of an EOB that read, “Alternative services were available, and should have been utilized.”  This statement could potentially interfere with the dentist-patient relationship. In this situation, the plan was immediately contacted by ADA staff to seek alternative language.
EOB language should provide information that clearly delineates the benefit limitations of the plan and any balance due to the dentist by the patient. It should not contain language that may disparage the dentist in any way.
 
To access the model EOB statement and to view the ADA’s position on EOB statements please visit:   https://success.ada.org/en/practice/dental-benefits/dental-benefit-basics/ada-position-on-explanation-of-benefits
  

Webinar - Advocacy and Third Party Issues
Click below to view this ADA webinar​​:

https://cc.readytalk.com/cc/playback/Playback.do?id=29ugyg

Implementation of D4346 In Your Office

By Teresa Duncan, MS, FAADOM

2017 gave us the new dental code D4346, however, confusion still exists around the usage and the coverage of this code. The code is interesting in that it was intended to fill a gap in coverage between those patients who need scaling and root planing and those who have a healthy mouth.

As a reminder, the code in its entirety is:
D4346 scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation The removal of plaque, calculus and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.

The confusion stems from its practical usage in the office and then on the coverage side of the code. The implementation of the code into practice is dependent upon a clinical team (both doctor and hygienist) who are able to confidently recommend the procedure. While this sounds simple, it’s often not. Many offices have differences in clinical opinions and so it’s important for the doctor and the hygiene team to share the same soft tissue management philosophy. Review cases with your team of when this code is most appropriate. You may see this in the mouth:
• Bleeding upon evaluation and probing but pocket depth is not alarming
• Inflamed gingiva but no evidence of bone loss on radiograph

Relaying the information to the patient when they are expecting “just a preventive visit’ can be problematic as well. It’s a good idea to practice your verbiage – as a team- so that it flows smoothly when the patient is in front of you. 

If the diagnosis of gingivitis is made, this code may be appropriate. The hygiene department should discuss how this code can change the flow of the patient’s visit. Keep in mind that a diagnosis is needed in order to recommend this procedure and to use the code D4346. The code is not meant to replace prophylaxis, scaling and root planing or osseous surgery. Rather it is meant to more accurately describe a common periodontal condition for which a code did not exist. Until your office is used to how this code is reimbursed, remember that this will be a confusing financial conversation. Being upfront about the cost is the number one rule of insurance and financial customer service. This leads me to the next confusion point.

What is the true cost to the patient? If insurance is involved then you will need to explain that no longer is this visit covered as a preventive measure. There is a real chance that not only will the patient’s deductible be applied but they’ll also have a copayment. Most insurance companies have been covering it but will provide benefits for a D1110 which is a lower fee. You are able to charge up to the contracted fee for D4346 but the difference between D1110 and D4346 will be borne by the patient. Sometimes this can be a significant amount if the deductible is large. Insurance coordinators will need to either call the insurance company or verify benefits online to ensure that they know how it will be processed. Add this to their many insurance-related tasks!

In order to have this conversation you’ll need visual evidence and strong verbal skills. Speaking the periodontal readings is a way to involve the patient in this process. Let them know what the numbers mean but also use your intraoral images to educate the patient. The fact that the necessity for D4346 is not evident on radiographs means that the camera is your best friend. Show your patient the inflammation that you see and gently point out that more bleeding is present than you would prefer. If you are not communicating this to the patient then it becomes more difficult for the administrative team members to discuss copayment. 

Administrative team members across the country have shared with me that even though benefits are being provided for prophylaxis, patients are not happy with the added out-of-pocket expense. Some teams have shared that they’ve stopped using the code as it’s just been problematic. If this sounds familiar then regroup! Have a team discussion on how this can fit into your clinical guidelines and commit to the following items:
• Attempt to find out how D4346 is covered during regular benefit checks.
• Practice (as a team) both the clinical and financial conversations for this code use.
• The insurance coordinator will follow up on claims to ensure that they are paid at least at the prophylaxis allowance. Appeals should be filed if applicable. 
• Increase efforts to document diagnosis so that claim requests for information are supported.

Implementing new codes are a team effort and should be approached as a group initiative. When everyone is on the same page then patients will benefit from consistent, effective and superior patient care. 

Teresa Duncan, MS, FAADOM is an international speaker who focuses on revenue, dental insurance & management issues. Her website features more insurance information along with online insurance training and a book on Insurance Conversations.
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