Medicare is for Americans who are 65 and older, and it’s an affordable approach to health care for all. While this federal program is great for keeping costs lowered in your golden years, it’s also notoriously confusing, particularly how it applies to dentists. Many dental practices are DME suppliers and have made Medicare work in their office by signing up as a nonparticipating DME supplier.

Since Medicare has placed oral appliances in the category of DME, you can “balance the bill” as a “nonparticipating” DME supplier. Nierman Practice Management can help you apply as a nonparticipating supplier. Nonparticipating doesn’t change the documentation rules, it changes the payment rules. Because of this, most Nierman Practice Management clientage sign up as non participating DME suppliers. This way, you can collect in full as a fee-for-service office with the reimbursement going to patients. The Medicare reimbursement fee varies depending on your location in the US.

Oral appliances for obstructive sleep apnea are covered under Durable Medical Equipment (DME). For Medicare to cover oral appliances for OSA, specific criteria must be met. The good news is that Medicare does spell out what’s needed in their policy, called the Local Coverage Determination (LCD) for Oral Appliances for OSA. To locate the policy and coding guidelines, search for “LCD for Oral Appliances for OSA” on the Internet.

To become eligible to bill Medicare for OAT, dentists must apply to become a Medicare Durable Medical Equipment (DME) supplier. Most people think of DME as equipment such as wheelchairs, CPAP, or diabetic supplies. So how does DME fit into a dental office? Dentists can become equipment suppliers not for the above-mentioned equipment, but for custom oral appliances. Once you become a DME supplier, a Medicare-approved appliance must be used.  The information relating to approved appliances can be found at www.dmepdac, where you can search for codes and fees and the DME Product Classification List for medical code E0486.

Medicare comes in 4 main parts, and understanding those parts can be a journey in itself. As a dental practice, it’s important to take the time to fully understand Medicare and what it’ll mean for your patients. That all starts with breaking down the different parts and seeing just what is and isn’t included in the program. Keep reading for an in-depth explanation of the different parts of Medicare.

Medicare Form

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Medicare Part A

Medicare Part A is hospital insurance. In essence, this will cover any expenses associated with a stay at a hospital or in hospice care. There are certain caveats to coverage that are worth looking into, however, to avoid any surprises later on. With Medicare Part A, patients receive a semi-private room and even skilled nursing staff. Medicare Part A also includes coverage for blood transfusions over 3 pints of blood.

Better yet, Part A is free as long as patients have worked at least 10 years in the United States. This part of Medicare covers room and board for any hospital stays, but it won’t necessarily cover all parts of care taking place within the hospital. Most of that will fall under Medicare Part B.

patient leaning on a walker wearing a hospital gown in a hospital room

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Medicare Part B

Like we said before, Part A doesn’t cover every treatment patients receive in the hospital or at another inpatient facility. Part B covers outpatient services that are seen by a doctor as medically necessary. This includes visits to doctors, lab tests, images, preventative care, any surgeries, ambulance rides, or radiation treatment. Even though many of these services might take place inside a hospital, they’re still considered Part B.

Patients need to have Medicare Part B coverage if they don’t have any additional coverage. It’s important to note that Medicare Part B does not cover things like dental, vision, or supplemental health services. However, Part B also has a category for Durable Medical Equipment (DME) for reimbursement of supplies and equipment such as CPAP or oral appliances for Obstructive Sleep Apnea. Medicare DME supplier status requires a separate application by the provider and many dentists are getting credentialed for oral appliances for OSA.

In fact, Nierman Practice Management helps dentists apply as DME suppliers, so they can help patients who are intolerant to or refuse CPAP with an oral appliance. Nierman Practice Management typically credentials DME dentists as nonparticipating DME suppliers. Being a nonparticipating DME doesn’t change the Medicare paperwork rules, it changes the payment rules, where the dental practice’s fee for the custom oral appliance is paid the beneficiary and the reimbursement check goes to the patient.

Medicare Part C

This part is usually the most confusing part of the entire process for patients and providers alike. Medicare Part C, like the other sections, is only for seniors 65 and older except in a few circumstances. You can think of Part C as private Medicare insurance. It’s also sometimes called Medicare Advantage, and it’s basically a private health plan patients can choose instead of traditional Medicare.

Private insurance carriers can offer Part A, Part B, and even Part D with their own network providers and premiums. These plans usually have lower premiums so they can be a more affordable option even though patients will often face higher copays. With Medicare Part C or an Advantage Plan, recipients have the option of including things like dental and vision insurance.

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Medicare Part D

Finally, Medicare Part D is designed to lower the cost of retail prescription drugs. While the other parts are all utilized through local Social Security offices, Part D plans are chosen through a private insurance carrier. This part of Medicare is optional.

By opting into Medicare Part D, patients will pay a premium monthly to this insurance carrier in return for significantly lowered copays on your medicines. While not everyone will need Medicare Part D, it’s important to learn about the enrollment period to avoid missing any important deadlines.

Making Smart Choices

When it comes to Medicare, it’s vital you understand the unique parts and how they’re all connected. Dental providers will be able to offer more ways to address their patients needs within the development of the Medicare program. Knowing how the different parts work will assist providers will providing quality service and the coverage their patients need.

Being proactive about the health of your patients includes knowing more about Medicare Part A, B, C, and D. Thanks to Medicare, all seniors have access to affordable, safe health services and preventative screenings.


About Guest Author: Ashley Lipman