Medicare Deadline Approaching: You In or are You Out?

Last year the Centers for Medicare and Medicaid Services (CMS) published a final rule requiring physicians and dentists who treat Medicare beneficiaries to either opt in or opt out or Medicare in order to prescribe medications to patients with Medicare Part D drug plans.

Dentists have until December 1, 2015 (updated) to take action. Failure to take action will result in the denied filling of prescriptions you write for your Medicare Part D eligible patients (imagine the phone calls your office will get from angry patients when their prescriptions cannot be filled at the pharmacy).

In a nutshell you have three choices. They are 1). Enroll to become a Medicare provider, 2). Enroll to become a referring dentist only, or 3) Opt out altogether. Before you decide let’s look at the consequences of each option.

Enroll to become a Participating Medicare Provider (Opt In)

For those of you who provide oral sleep appliances, which are covered by Medicare, if you opt in your reimbursement for oral sleep appliances is limited to Medicare’s reimbursement schedule (get out your checkbook, being you will limited to Medicare’s fee schedule it may actually cost YOU each time you provide an oral sleep appliance for a patient).

Secondly, like your colleagues who are Medicaid providers you will be required to implement and maintain a healthcare compliance program, which includes sanctions monitoring of you, your contractors and employees on a monthly basis, implementation of a corporate compliance plan, completion of additional compliance training requirements, implementation of auditing processes relative to clinical documentation and billing AND the burden of maintaining adequate records to demonstrate the effectiveness of your healthcare compliance program.

I’ve written a lot about healthcare compliance programs in recent months, but let’s review the essential elements in case you missed out:

  1. Establish auditing and monitoring processes (a topic that really deserves its own book series) including clinical documentation and billing records, federal and applicable state sanctions screening/ monitoring and monitoring for changes in rules and regulations by which you and your practice and bound to abide by.
  2. Appoint a high-level person within your organization to be your corporate compliance officer (larger organizations should implement a compliance committee to steer compliance functions and provide direction to the compliance officer) that are given the resources and authority to oversee compliance efforts, establish your compliance program/ policies and procedures, enforce internal policies and keep up with changing regulations and enforcement trends.
  3. Establish written policies and procedures to address areas of high risk, and mandate compliance with regulatory standards including, but not limited to OSHA; HIPAA; Fraud, Waste and Abuse; Medicare (Medicaid) program requirements, Dental Practice Act, Anti Kickback Statute/ Physician (Stark) Referral Laws.
  4. Communicate your internal standards and external rules and regulations to your contractors and employees.
  5. Enforce your written policies and procedures to your contractors and employees through.
  6. Establish internal reporting mechanism (open door policy), which enables your contractors and employees to communicate compliance and ethics concerns to you or your compliance officer anonymously.
  7. Ensure an appropriate response to detected or reported violations of internal standards and external rules and regulations supported by adequate documentation to demonstrate the response.

If you are not up to the task of subscribing to Medicare’s reimbursement schedule and the onerous rules and regulations then opting in is not for you.

Enroll to become an Ordering and Referring (only) Medicare Provider (Opt In)

If you decide to be an ordering and referring provider only you are not recognized as a Medicare provider, but any orders or referrals you make for Medicare covered testing, services, or care by subsequent providers is reimbursable based on your status as an ordering and referring provider. What this means is if you refer a Medicare beneficiary patient to OMS for evaluation of an oral lesion, the lesion turns out to be cancerous, the lesion is excised and the patient is then referred to oncology the OMS and the oncologist will be able to get paid for their services, which stemmed from your referral of the patient.

If you were not a Medicare provider or at least an ordering and referring provider then neither the OMS nor the oncologist (or anyone else involved in the care of this patient) would be able to be reimbursed by Medicare for their services for this patient, which stemmed from your referral as an opted out provider. Sound fair? Certainly not, but that is exactly the ploy the federal government is using to save an estimated $1.6 billion dollars for healthcare in the next decade.

As an ordering and referring provider you are also bound to comply with Medicare mandates that you have a healthcare compliance program, which I described above, so being an Ordering and Referring Provider may not be the right option for you either.

Medicare Opt Out

Lastly, you can always opt out of participation with Medicare. In the previous section I outlined a substantial drawback of opting out (your OMS and area physicians may not be have warm fuzzies about you when they realize you sent them a patient they have to care for, but will not get paid for treating because you chose to opt out of Medicare). This could result in a cold shoulder or two at the local country club (and perhaps a few lonely rounds of golf).

The up side of opting out of Medicare is you are not limited by Medicare’s fee schedule and can enter into private pay contracts with your patients if you happen to provide service, like OSAs, for Medicare recipients. You also would not have to bother with establishing or maintaining a healthcare compliance program and all the work they entail.

How to Opt In, Opt In as an Ordering and Referring Provider, or Opt Out of Medicare

Opting In is simple. Go to the online Medicare Provider Enrollment, Chain, and Ownership System (PECOS), create a log in and complete the provider enrollment application ( A number of my clients have had difficulties with PECOS and elected to complete paper applications (CMS-8551), which can be found online (

If you have decided to be an Ordering and Referring Provider you can also do that through PECOS ( You can also complete a paper application (CMS-8550), which can be found online (

NOTE: If you complete either paper application you need to go to ( to identify which Medicare Administrative Contractor (MAC) to submit your completed application to.

As I researched the mechanics of how to opt out I discovered there is no uniform application. If you have decided to opt out of Medicare go to your MAC website (click here to find the MAC for your area, obtain, complete and submit a Medicare Opt Out Affidavit to the Mac for your area.

For those of you in Texas the MAC is Novitas Solutions. Click here to obtain an opt out affidavit. Completed affidavits should be submitted to Provider Enrollment Services, Novitas Solutions, P.O. Box 3095, Mechanicsburg, PA 17055-1813 or by Fax to 717-728-8759.

Notify Your Patients and Area Specialists

If you elect to opt out be sure to notify the specialists in your area of your decision, as your decision could impact them. Also, be sure to notify your patients that you opted out of Medicare. Your decision to opt-out is binding for 2 years. If you decide to opt in later you can do so at the end of the two-year period.


You need to understand your compliance strengths and weaknesses. You need to address your weaknesses. I invite you to complete a free self-audit at

A former Law Enforcement Officer/ Dental Board investigator Mr. Duane Tinker is the CEO of Dental Compliance Specialists. Mr. Tinker and his compliance specialists provide compliance consulting, auditing and training services for dentists and Dental Service Organizations nationwide on compliance risks including OSHA, HIPAA, Dental Board rules/ regulations, state radiology rules, DEA and state drug regulations, and Medicaid. He often speaks for dental societies and study clubs. Mr. Tinker can be reached at (817) 755-0035 or