In dentistry, Medicare seems overwhelming, frightening, difficult and frankly, you can fill in the blank. Even as I was researching the differences, I had to put things away because my brain was getting completely scrambled. So, now think of your Medicare age patients that are dealing with this alone! This is an epidemic that we will all face when we reach 65-72.
In order to help you determine what kind of Medicare provider (each office must pick one) your practice would like to be, here are some hints and descriptions that might help you:
- Participating Provider: This dentist will accept Medicare and always take assignment of benefits and agree to the Medicare approved amount for health care services as full payment (not including the deductible or co-pay).∗These providers are required to submit a claim to Medicare for care provided. Medicare will process the bill and pay you directly for covered services. Your patient will be responsible for paying the 20% co-insurance for Medicare covered services (if the service is not covered by Medicare, please make sure your patient signs an ABN form (Advanced Beneficiary Notification) stating that specific services are not covered under Medicare and the patient is responsible.
- Non-Participating Provider: This dentist accepts Medicare, but they do not agree to accept assignment of benefits. This means that the provider does not accept the Medicare fee as full payment of service.∗Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services provided (known as the limiting charge). This means the patient will be responsible for 35% (20% co-insurance + 15% limiting charge) of Medicare’s approved amount for covered services.
∗Some states may restrict the limiting charge when you see non-participating providers. One example is New York State’s limiting charge is set at 5% instead of 15% for most services. Is best to contact your State Health Insurance Assistance Program for more state specific information.
∗The limiting charge rules do not apply to DME (durable medical equipment).
- Opt-out Providers: These dentists do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services and must follow certain rules to do so:∗Medicare will not pay for care except in emergencies (services will be limited). Patients will be responsible for entire cost.
∗You must give your patient a private contract describing their charges and confirm with the patient that they are responsible for the full cost and that Medicare will not reimburse the practice or the patient.
∗Opt-out providers do not bill Medicare for services.
For more details on the various plans see Medicare/Medigap Plans A-D, F-G, K-N Explained
Laurie Owens, CPB, CPC
Director of Medical Billing Education