Did you know that congress has not amended dental coverage under Medicare since 1980 when the blanket exclusion of coverage was first in effect?
That is a big gap of time for questions to linger and mistakes to be made in billing dental to Medicare. Let us help bridge that gap!
This read is every bit worth it.
1. Know Coverage Principle Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed.
2. Familiarize yourself with the dental coverage for A + B:
Medicare doesn't cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices. Medicare Part A (Hospital Insurance)will pay for certain dental services that you get when you're in a hospital. Part A can pay for inpatient hospital care if you need to have an emergency or complicated dental procedures, even though it doesn't cover dental care.
3. Medicare Advantage (Part C) is a company contracted with Medicare and is an additional expense to the patient. These plans can offer coverage for dental and vision health items in addition to also offering the same coverage as Original Medicare. Most also include prescription drug coverage as well as other benefits such as hearing health coverage and gym memberships.
4. Have the Patient Sign the ABN if Medicare will not Cover a Service/Item: If Medicare does not cover a service/item that the patient wants, it is important that the patient signs the ABN (Advanced Beneficiary Notification) form. This confirms that the patient understands that Medicare will not cover the service/item and agrees to pay out of pocket for it. ABN forms are not necessary for things that Medicare typically doesn’t cover such as routine dental services like cleaning, root canals, etc.
5. Verify Benefits. Benefits for any type of Medicare Advantage plan can vary. Know policy effective dates, obtain prior authorizations or pre-determination of benefits, and verify what the patient will be required to pay. We also encourage you to record any calls for verification to help when needing to appeal a claim as well. This is included in all of our support.
6. Use the Medicare Beneficiary Identifier (MBI)
Beginning in 2020, Medicare did away with using a beneficiary’s Social Security number for billing purposes. Dentists must now use the 11-character alphanumeric MBI when billing Medicare. Failure to use the MBI, or even a failure to enter it correctly, could result in a rejected claim.
The MBI uses numerals 0-9 and uppercase letters only. The letters B, I, L, O, S, and Z are not used, and no hyphens or spaces should be included when entering the MBI on a claim form. Also, replace the Social Security number with the MBI in patient records.
7. Wait on the Part B deductible
If you accept Medicare assignment, the Centers for Medicare & Medicaid Services (CMS) recommends not charging or collecting the Medicare Part B deductible amount from a patient until you can confirm whether or not it has been met. The reason for this is that if you end up over-collecting, the CMS may consider this abuse, and it could lead to part of your reimbursement check being sent to the beneficiary. Or you might face a demand letter from the Medicare Administrative Contractor (MAC) outlining a repayment request. Neither is good for your bottom line.
8. Know the Stark Law changes
You may be familiar with the Stark Law, which prohibits you from referring Medicare and Medicaid patients to entities with which you have a financial relationship. But are you familiar with the changes to the law that went into effect in January 2021? Brush up on the changes to see how the new regulations can create more streamlined revenue opportunities for your practice.
9. Remain up-to-date on coverage determinations
What’s covered or not covered by Medicare is largely in the hands of Local Coverage Determinations, National Coverage Determinations, and Medicare Administrative Contractors. Staying in the know about these coverage decisions can help you better shape the service offerings of your practice. Signing up to receive CMS listserv updates can help keep you informed.
10. Follow Up. Stay on top of your outstanding claims. Honestly, every reason in the book comes up as to why claims are denied or delayed. Sometimes they could even fully process but the payment is sent to the patient.... see #7!! Need help?
These materials are intended to provide helpful information to dentists and dental team members. They are in no way a substitute for actual professional advice based upon your unique facts and circumstances. This content is not intended or offered, nor should it be taken, as legal or other professional advice. You should always consult with your own professional advisors (e.g. attorney, accountant, insurance carrier). To the extent Dentistry Support, LLC TM has included links to any third party website (s), Dentistry Support, LLC TM intends no endorsement of their content and implies no affiliation with the organizations that provide their content. Further, Dentistry Support, LLC TM makes no representations or warranties about the information provided on those sites.