DO YOU NEED HELP GETTING A MEDICARE NUMBER (PTAN and/or DME)?
(The following information contained is copyrighted and taken verbatim from the 2017 “Z Book”, aka “Accessing Medical Benefits in the Comprehensive Dental and Surgical Practice”)
STEP 1: DETERMINE WHETHER BECOMING A MEDICARE PROVIDER IS WORTH IT TO YOUR PRACTICE
Do you have Medicare-insured patients who require these procedures?
1. REMOVAL OF PATHOLOGY, BOTH SOFT AND HARD TISSUE
This includes pathology as it relates to lesions, but excludes pathology that is tooth-related, ie. Abscesses, cysts, etc.
2. TREATMENT RELATED TO CANCER OR TUMOR REMOVAL
Patients that have had any type of treatment that resulted in damage to the oral structures, be it chemotherapy, radiation, or surgery, typically are covered for repairing of the damage.
3. TREATMENT RELATED TO TRAUMA
Patients that have sustained traumatic injury to their jaw/teeth will be covered for extraction of those teeth as part of the repair of the fractured jaw. Reduction of the fracture, as well as wiring of the jaws/teeth is also covered.
4. TREATMENT OF SLEEP APNEA
Sleep studies and appliance therapies, as well as surgical correction for airway obstruction.
STEP 2: DETERMINE WHICH PROVIDER STATUS YOU WISH TO APPLY FOR
What is the difference between the different provider statuses? Here is an explanation, taken from the 2017 “Z Book”, aka “Accessing Medical Benefits in the Comprehensive Dental and Surgical Practice”©
i. PARTICIPATING (PAR) PROVIDERS
· agree to accept Medicare allowable fees for procedures billed to Medicare
· are paid directly by Medicare for covered procedures
· are paid automatically and directly by the supplement (if the patient has supplemental coverage), without having to submit another claim for any deductible and co-payment
· CANNOT balance bill patient over and above the Medicare allowable fee
· If you also wish to bill Medicare for sleep apnea appliances, a SEPARATE DMEPOS number is required
ii. NON-PARTICIPATING (non-PAR) PROVIDERS
· agree to accept Medicare Non-Participating Provider fees for procedures billed to Medicare (Non-PAR Allowable benefit is 95% of the PAR Allowable benefit)
· have the option of either Accepting Assignment or Not Accepting Assignment on a claim by claim basis
· are paid directly by Medicare for covered procedures, when they Accept Assignment
IF THE non-PAR PROVIDER DOES NOT ACCEPT ASSIGNMENT, then payment in the amount of 80% of the Medicare non-PAR benefit will go to the Patient, and the Provider can then collect ONLY UP TO THE MEDICARE LIMITING CHARGE.
iii. "ORDERING AND REFERRING" PROVIDERS
· cannot send claims for their services to Medicare for reimbursement
· will be placed on the Medicare Ordering and Referring Registry
· will be able to order prescriptions, laboratory services, and refer patients to Medicare-enrolled providers and suppliers
Patients will not pay out of pocket for services provided by these Medicare providers, including pharmacies.
iv. DMEPOS PROVIDERS
· can only bill for covered appliance, i.e. sleep apnea appliances
· must obtain a separate DMEPOS number (DMEPOS=Durable medical equipment. prosthetics, orthotics, and supplies)