Medicare Enrollment Deadline Looms for Delaware Dentists

Written By Nate Trexler

Most dentists have never had the need to consider Medicare enrollment, based on the fact that Medicare Part B covers a small amount of dental services (for example, services that are an integral part of a covered procedure and for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw).  But for the many dentists who treat Medicare patients with Part D prescription drug plans, June 1, 2015 marks an important deadline.

Last May, the Centers for Medicare and Medicaid Services (“CMS”) published a final rule that requires dentists to either enroll in or opt out of Medicare in order to prescribe Medicare covered medication to qualifying patients with Part D prescription drug plans.  If a dentist does not enroll or opt out, but prescribes such medication to his or her patient, the Part D sponsor or its pharmaceutical benefit manager must deny the pharmacy claim for the drug.  The Part D sponsor or its pharmaceutical benefit manager must also deny requests for reimbursement from patients for a drug prescribed by a dentist that has not enrolled in or opted out of Medicare.  CMS has directed dentists to either enroll in or opt out of Medicare by June 1, 2015 in order to ensure sufficient processing time for their patients’ prescription drug claims and to prevent claims from being denied by Part D plans.

While dentists are not billing or receiving payment for prescription drugs, the practical concern is how pharmacies and patients will react.  It is possible that a pharmacy will refuse a prescription, knowing it will be denied payment, or make the patient pay out of pocket.  Patients, then, will suffer a similar denial for reimbursement from the drug plan.  Unfortunately, all fingers will point back to the dentist who prescribed the necessary medication, but who did not enroll in or opt out of Medicare.

When examining the options CMS has provided, “opting out” may seem like the simple solution.   However, opting out is not quite as simple as informing Medicare that you are choosing not to enroll.  To become an “opt-out provider,” the dentist must file an affidavit with the regional Medicare Administrative Contractor and enter into private contracts with each patient.  These contracts must meet specific requirements.

On the other hand, dentists may enroll as a “full” provider or as only an “ordering/referring” provider.  Enrolling as an “ordering/referring provider” will enable patients to receive coverage for prescription drugs and will also allow colleagues to whom you refer Medicare Part B covered services to receive Medicare reimbursement.  Each of these options has different requirements and forms.

The ADA voiced opposition to the rule, noting that this new requirement will affect the majority of dental practices.  Delaware dentists should consider their enrollment options and, if prescribing medication to Medicare beneficiaries covered by a Part D plan, submit an enrollment application or opt-out affidavit by June 1, 2015.

New Rule Expands Bases on Which Providers Can Be Excluded from Participation in Medicare

Written By Melony Anderson 

On December 3, the Centers for Medicare & Medicaid Services (“CMS”) issued a new rule that enhances CMS’s ability to exclude or remove providers from participation in Medicare.  According to a press release issued by CMS, the new rule is designed to “prevent physicians and other providers with unpaid debt from re-entering Medicare, remove providers with patterns or practices of abusive billing, and implement other provisions to help save more than $327 million annually.”

The new rule has several provisions.  The first, and most significant given CMS’s stated purpose for the rule, is as follows:

CMS may now deny enrollment if the provider, supplier or owner thereof was previously the owner of a provider or supplier that had a Medicare debt that existed when the latter’s enrollment was voluntarily terminated, involuntarily terminated or revoked AND

·   The owner left the provider or supplier that had the Medicare debt within 1 year of that provider or supplier’s voluntary termination, involuntary termination, or revocation;

·   The Medicare debt has not been fully repaid; AND

·   CMS determines that the uncollected debt poses an undue risk of fraud, waste or abuse.

There are terms under which the provider, supplier or owner thereof can avert the denial, including repaying the debt in full, or agreeing to a repayment schedule for the entire debt if the provider meets the criteria for an extended repayment schedule provided by 42 C.F.R. §401.607.

 

To illustrate how this rule may be applied, consider the following example.  Provider ABC is owned by Owner X.  ABC terminates its enrollment in Medicare.  At the time of the termination, ABC had an outstanding Medicare debt.  Owner X leaves ABC less than a year after the termination.  Thereafter, as long as ABC’s debt remains unpaid, Owner X may be excluded from participating in Medicare, either as a provider or supplier or as an owner thereof, if CMS determines that the outstanding debt poses an “undue risk of fraud, waste or abuse.”  It is not clear from the rules what CMS considers to constitute an “undue risk”, and whether that is based on a dollar figure, or some other criteria.  Owner X may avoid denial if he/she agrees to a repayment schedule for the debt, or pays the debt in full. 

The new rule also expands the bases on which CMS can deny enrollment or revoke billing privileges based on prior felony convictions.  Under the prior rule, CMS could deny enrollment to any provider, supplier or owner who was convicted of a state or federal felony in the prior 10 years.   The new rule expands that to include “managing employees”. 

CMS can now revoke Medicare billing privileges if the provider or supplier has a “pattern or practice of submitting claims that fail to meet Medicare requirements”, including the requirement that the service be reasonable and necessary.  Many commenters to the proposed rule suggested that the provision was arbitrary and subjective, granting too much discretion to CMS.  CMS responded by stating that “sporadic billing errors would not result in revocation”.  CMS does not define “pattern or practice”, but listed several factors that would be considered, including:  (1) percentage of submitted claims that were denied; (2) total number of claims denied; (3) the reason(s) for the claim denials; (4) whether there is a history of final adverse actions; (5) the time period over which the pattern has continued; and (6) how long the provider has been enrolled in Medicare.  With respect to factors (1) and (2), CMS declined to establish objective numerical thresholds. 

The new rule also provides that revoked providers must submit all remaining claims within 60 days after revocation.  Revoked providers and suppliers may now only submit a corrective action plan where the revocation was based on noncompliance with the enrollment requirements, or the enrollment application.  In other words, a revocation based on provider or supplier conduct is no longer eligible for a corrective action plan.

The new rule goes into effect on February 3, 2015.