Thursday Troubleshooter: If they opt out, can this practice accept ANY Medicare plans?

QUESTION: The oral surgeons I work with are contracted with many medical as well as dental insurance plans, but they have recently opted out of Medicare. In doing so, Medicare informed us we can no longer accept ANY plans affiliated with Medicare. For example, Humana has a dental rider on the medical plan. It's very limited and mostly preventive, but it allows two extractions per year then acts as a discount plan. If the surgeons accept any plans affiliated with Medicare, Medicare will consider them back in.

However, these plans are part of the Diversified Network Fee Schedule. Diversified tells us that we are in breach of contract with them if we do not honor the contract write-off.

Many dentists honor the write-off on these limited plans through Medicare, but they have never been contracted with Medicare or any medical. Can you tell me which is correct? Do we honor the Medicare regulations or the Diversified contract?

ANSWER FROM TERRI BRADLEY of Terri Bradley Consulting:
When you opt out of Medicare you are signing an opt-out affidavit with Medicare and entering into a private contract with each Medicare patient you treat in your office. By opting out of Medicare you are essentially telling Medicare and your patients that you will not submit any claims to Medicare (even for services that may have potentially been covered by Medicare), and by signing the contract the patient is also agreeing not to submit claims to Medicare for services rendered in your office.

The opt-out affidavits and contracts expire every two years, so the process has to be repeated if you want to maintain your opt-out status with Medicare. By opting out, a provider is opting out of Part B Medicare (traditional Medicare plans) as well as Medicare Advantage plans (may be referred to as Medicare+ Choice or Medicare Part C).

There are many Medicare Advantage plans that have coverage beyond traditional Medicare coverage (i.e., dental services). There are some Medicare Advantage Plans that will not cover services or claims under these plans if the provider has opted out of Medicare.

Part of what you were told is incorrect. If you file a claim with a Medicare Advantage insurance carrier, it may or may not be covered by the insurance carrier, depending on whether they will provide benefits to an out-of-network or opted-out Medicare provider. By filing a claim you would not be re-enrolled in Medicare. You have to fulfill the two-year time of the current opt-out period.

You must first follow the Medicare regulations, and it sounds like you are following them with your opt-out status. What you need to find out is whether or not Diversified Network Fee will pay for the Medicare Advantage plan patients for a provider that has opted out of Medicare. What Diversified Network Fee may be telling you is that you may have to honor the discount even if services are not covered.

You do not need to worry that submitting a claim to Medicare Advantage plan will change your opt-out status.

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