April 04, 2019 • 7 min read

Billing Medicare For Dentistry & The Types of Providers

The article provides guidance on billing Medicare for dentistry, including accepting Medicare as a participating provider and paying full payment without deductible or co-pay.



Laurie Owens

CPC | CPB | COC | Director Of Medical Billing Education for Devdent

Billing Medicare For Dentistry
Medicare Care For Dentistry

Billing Medicare for dentistry can seem overwhelming. However, in order to help you here is some guidance that might help you make your decision and show you the potential of it in your practice. So which type is right for you?

Participating Provider

When billing Medicare for dentistry as a participating provider you do accept Medicare and you always take the assignment of benefits. This means you agree to the Medicare-approved amount for health care services as full payment. This does not include the deductible or co-pay. Medicare will process the claim and pay you directly for covered services. The patient is responsible for paying the 20% co-insurance for all Medicare-covered services.

ABN (Advanced Beneficiary Notification)

If the procedure/service is not covered by Medicare, it is important that you get a signed ABN (Advanced Beneficiary Notification) form. You can download instructions on how to fill out an ABN form on the Centers For Medicare and Medicaid website. This form confirms that the patient understands the procedure is not covered by their medicare. If, based on Medicare coverage rules, you have reason to believe that Medicare will not pay for the service. The ABN form must follow the below criteria.

  • The ABN form cant be:
    • Difficult to read or hard to understand

    • Given by the provider to every patient with no specific reason as to why a claim may be denied

    • Missing a list of the actual service(s) provided

    • Signed after the date the service was provided

    • Given to the patient during an emergency or given just prior to the patient receiving a service (for instance, immediately before a procedure)
Billing Medicare For Dentistry
Non-Participating Provider

When billing Medicare for dentistry as a non-participating provider, you do accept Medicare. However, you do not agree to always accept assignment of benefits. Meaning that as the provider you do not accept the Medicare fee as full payment of service. Because of this non-participating providers can utilize a limiting charge. Which allows you to bill up to 15% more than Medicare’s approved amount. As a result, the patient is responsible for 35 percent (20 percent co-insurance + 15 percent limiting charge) of Medicare’s approved amount for covered services.

Be sure to check your local medicare laws. Some states may restrict the limiting charge when patients see non-participating providers. For example, New York State’s limiting charge is set at 5% instead of the regular 15% for most services. So as a safe rule of thumb, contact your State Health Insurance Assistance Program for more state-specific information.

*The Limiting charge rule does not apply to DME (durable medical equipment).

Opt-out Providers

As an opt-out provider, you do not accept Medicare at all. As a result, you have a signed agreement that excludes you from the Medicare program.  This means you can charge whatever you see fit for services rendered. With that said you still need to follow several rules. Medicare does not pay for care except in emergencies but services will be limited. The patients are entirely responsible for any procedure or service. You must provide your patient with a private contract giving a detailed breakdown of their charges. The contract confirms that the patient is responsible for the entire procedure cost. Because Medicare will not reimburse the practice or the patient.

*Opt-out providers do not bill Medicare for services.

Is Billing Medicare for Dentistry Right For You?

Billing Medicare for dentistry can be a great tool for your practice. It also is a benefit that you can pass onto your Medicare patients. The type of medicare provider you want to be is open to what fit is best for your office. If you have any further questions you can contact us.

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