AFFORDABLE CARE ACT—MEDICARE UPDATES AFFECT DENTISTS

Knowing that the original Medicare program excludes coverage for routine dental services, most dentists have historically turned a deaf ear to Medicare enrollment information. Not dealing with Medicare may have worked for the majority of dentists in the past. However, two recent changes introduced by the Affordable Care Act will directly affect dentists, making it even more important for all dentists to understand their options and responsibilities under Medicare.

 CMS simplifies form for dentists who only want to order or refer services for Medicare patients. Section 6405 of the Affordable Care Act permits dentists to enroll in Medicare for the sole purpose of ordering or referring items or services for Medicare beneficiaries. If a Medicare patient’s dentist has not enrolled in Medicare (as either a participating or non-participating provider) OR has not enrolled in Medicare as only an ordering/referring provider, claims for services that require the name and NPI of the ordering/referring provider will be denied. For example, if a dentist sends a biopsy specimen to an oral pathology lab but has not enrolled in Medicare as an ordering/referring provider, the Medicare patient’s oral pathology lab claim will not be paid. This, of course, will be a concern to the Medicare patient and the oral pathology lab.

“If a dentist sends a biopsy specimen to an oral pathology lab but has not enrolled in Medicare as an ordering/referring provider, the Medicare patient’s oral pathology

lab claim will not be paid.”

Although the most recent enforcement deadline (July 5, 2011) has passed, CMS (to our knowledge) has not begun rejecting Medicare claims if the ordering/referring provider has not enrolled in the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS). Instead, CMS recently announced the development of a simplified enrollment form for health care providers (including dentists) who do not want to submit claims to Medicare but do want to be allowed to order/refer certain services. The new form is not necessary for dentists who have already enrolled in Medicare for the purpose of submitting claims. Dentists can apply for enrollment for the sole purpose of ordering and referring items and services to beneficiaries in the Medicare program using either Internet-based PECOS or the new simplified paper enrollment application process (CMS855O). Additional information regarding the Medicare enrollment process, including PECOS, can be found at www.cms.gov/

MedicareProviderSupEnroll.

Medicare requires providers to revalidate and initiates enrollment fee.

Section 6401(1) of the Affordable Care Act established a requirement for all providers (including dentists) who enrolled in Medicare (or revalidated their information either on paper or through PECOS) prior to March 25, 2011 to revalidate their Medicare information again and pay a new application fee authorized by Congress. This also applies to dentists who Medicare requires providers to revalidate and initiates enrollment fee.

Section 6401(1) of the Affordable Care Act established a requirement for all providers (including dentists) who enrolled in Medicare (or revalidated their information either on paper or through PECOS) prior to March 25, 2011 to revalidate their Medicare information again and pay a new application fee authorized by Congress. This also applies to dentists who provide sleep apnea appliances to Medicare patients and who have enrolled in Medicare as a DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) supplier using Medicare form CMS-855S.

Between now and March 23, 2013, Medicare carriers will send out revalidation notices to each Medicare provider and DMEPOS supplier. Providers should not submit their revalidation until asked to do so by their local Medicare carrier. Dentists who enrolled in Medicare as a participating or non-participating provider or as a DMEPOS provider on or after March 25, 2011, are not affected. Providers and suppliers have 60 days from the date of the Medicare carrier’s letter to submit complete enrollment forms. Failure to revalidate and submit the enrollment form will result in the deactivation of the provider’s Medicare billing privileges.

The Affordable Care Act requires CMS to impose a fee on each “institutional provider of medical or other items or services and suppliers.” The application fee for the remainder of 2011 is $505. This was raised to around $550.00 The revalidation fee for future years will be adjusted by the percentage change in the consumer price index for the twelve-month period ending on June 30 of the prior year. CMS defines “institutional provider” to mean any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A, CMS-855B, CMS-855S, or associated Internetbased PECOS enrollment application. All providers/suppliers who respond to a revalidation request must submit their enrollment fee via www.pay.gov.