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American Association of Oral and Maxillofacial Surgeons

Reimbursement FAQ

Medicare
  1. Opting Out/Private Contracting
  2. Medicare Opt Out for Non-Enrolled OMSs
  3. Group Practice Opting-Out
  4. Treating Emergency Room Patients
  5. ABN
  6. Medicare Prior Determination
  7. Medicare Rule and Opted-Out Providers
  8. Medicare Advantage
  9. Current Enrollment Records in Medicare
Medicare E-Prescribing
  1. E-Prescribing Defined
  2. E-Prescribing Systems
  3. Eligible Professionals
  4. Non-Participation
  5. E-Prescribing Incentive Program Qualifications
Bundling Payment
  1. Bundling Payment for Anesthesia Services
Coordinating Benefits
  1. Coordinating Medical and Dental Benefits
  2. Coordinating Benefit Coverage of Divorced Parents
  3. Overpayments from Secondary Insurance
Professional Courtesy
  1. Overview of Professional Courtesy and Discounts
Appeals
  1. Orthognathic Surgery Denials
Managed Care
  1. Fees for Non-Covered Services

The information provided to you is intended for educational purposes only. In no event shall AAOMS be liable for any decision made or action taken or not taken by you or anyone else in reliance on the information provided. For legal or other professional advice, you need to consult your own professional advisers.


Question:

I do not wish to participate with Medicare nor submit claims to Medicare any longer, however would like to continue to treat Medicare patients by privately contracting with them. Is this possible, and if so, what do I need to do?

Answer:

Section 603 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173) extends the legal authority to "opt-out" of Medicare to dentists, allowing dentists, including OMSs to enter into private contracts with patients who are Medicare beneficiaries. To opt-out of Medicare, an OMS must submit a properly completed affidavit with each Medicare carrier in which he or she normally files claims. For an OMS categorized as a non-participating physician, the opt-out period may begin within 10 days of signing the first private contract with a Medicare beneficiary. An OMS who is a participating physician under Medicare may initiate an opt-out period at the beginning of any calendar quarter, provided that the affidavit is submitted to the carrier at least 30 days prior to the beginning of the quarter.

Once the Opt-out period has begun, OMSs must enter into a signed Private Contract with every Medicare beneficiary treated during the two year opt-out period. This notifies the patient of your Medicare status as well as provides you with the patient's signed acknowledgement and agreement to be financially responsible for your services. If a patient refuses to sign the private contract, the patient should be referred to a Medicare provider.

Keep in mind, OMSs may not privately contract with new Medicare patients treated in the emergency room. Claims must be submitted on the behalf of Medicare patients treated in the emergency room if a private contract had not been previously signed. Therefore, an OMS must have been enrolled in Medicare prior to opting out in order to submit a claim for reimbursement. Those OMSs not currently enrolled and interested in opting out, and occasionally treat emergency room patients it is recommended that you enroll in Medicare before opting out.

Links to a sample affidavit and private contract are provided below. Additional information for opted out physicians are covered in the next two questions.

Keep in mind, an OMS who has not properly opted out and enters into a private contract with a Medicare beneficiary for items and services covered by Medicare may be at risk for fines and penalties, including exclusion from Medicare and other federal health programs.

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Question:

May an OMS who has never enrolled in Medicare opt out of Medicare?

Answer:

Yes. An OMS who has never enrolled in Medicare may opt out of Medicare by completing an affidavit. However, an OMS that has never been enrolled must provide additional information such as tax identification number, year of graduation, name of school, and license number. Your local Medicare Carrier may have a standard affidavit which includes a section for those who have never enrolled. If not, you may customize the AAOMS sample affidavit.

As mentioned above, OMSs may not privately contract with new Medicare patients treated in the emergency room. Claims must be submitted on the behalf of Medicare patients treated in the emergency room if a private contract has not been previously signed. Therefore, an OMS must have been enrolled in Medicare prior to opting out in order to submit claims for reimbursement. If you are not currently enrolled, and wish to opt out but occasionally treat emergency room patients, it is recommended that you enroll in Medicare before opting out. See the next question for additional information related to submitting claims for emergency room services.

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Question:

When opting out of Medicare, does each physician in the practice have to opt-out together or can each physician make their own decision?

Answer:

When a physician opts out and is a member of a group practice, the organization may no longer bill Medicare or be paid by Medicare for services the physician provides to Medicare beneficiaries. However, if the physician continues to provide the practice the right to bill and be paid for the services provided by that physician to Medicare patients, the organization may bill and be paid by the beneficiary for the services that are provided under the private contract. The decision of one physician within the group to opt out of Medicare does not affect the ability of the group practice to bill Medicare for the services of those physicians within the practice who have not opted out of Medicare.

If every physician within the group practice or corporation opts out, then such practice or corporation would have, in effect, opted out.

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Question:

How does an OMS who has opted out receive reimbursement for emergency room services rendered to a Medicare beneficiary they have never seen before?

Answer:

Medicare will pay for emergency or urgent care services furnished to Medicare beneficiaries who have not previously signed a private contract with the OMS prior to the emergency service. This is the only exception to the Medicare policy which prohibits physicians who have opted out from submitting claims to Medicare. When an OMS who has opted out treats a Medicare beneficiary who has not signed a private contract in an emergency situation, the OMS must submit the claim on the patient's behalf. The claim should be submitted with the HCPCS modifier "GJ"- "Opt Out" physician or practitioner emergency or urgent service". The "GJ" indicates to Medicare that the service provided was rendered by an OMS who has opted out and has not signed a private contract with this particular beneficiary therefore the service should be submitted and paid. Keep in mind that Medicare's typical allowed amounts and limiting charges apply.

In the event that surgery is required, the surgical procedure should also contain the modifier 54- "Surgical Care Only" so that the E/M that is in the global fee for the procedure is not paid. The patient may then sign a private contract for any post-operative care rendered in the office or may be referred to Medicare provider who would bill Medicare using modifier "54- Post Operative Management Only".

If a Medicare patient with whom a signed private contract has been obtained is treated in the emergency room a claim would not need to be submitted as the private contract is valid for any and all services rendered to the patient within the OMS's opt out period.

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Question:

What changes have the Centers for Medicare and Medicaid Services (CMS) made to the ABN?

Answer:

Use of the revised version of the Advance Beneficiary Notice (ABN) form will take effect March 1, 2009. The revised form has a new name: "Advance Beneficiary Notice of Noncoverage" however will still be referred to as the "ABN". The cost-estimate field is new to the final form and critical to remaining in compliance. It is therefore mandatory to complete this field. The form should continue to be provided to Medicare beneficiaries before rendering a service that is likely to be denied by Medicare.

The four key changes to the new ABN form are as follows:

  • It is a consolidated version of the two existing ABN forms, the ABN-G for general services and the ABN-L for lab services, so it replaces both;
  • it may replace the use of the Notice of Exclusion from Medicare Benefits form (NEMB);
  • provides a field to indicate the cost estimate of the service(s) being performed (mandatory); and
  • it includes a new option for beneficiaries that allows them to choose a service for which they will pay out-of-pocket, without having a claim submitted to Medicare

To download a copy of the ABN visit the Beneficiary Notices Section of the CMS Web site. For more information, visit the Use of the Medicare Advanced Beneficiary Notice (ABN) page of the AAOMS Web site and the CMS Medicare Learning Network "Advanced Beneficiary Notice of Noncoverage (ABN)" booklet which provides information on when providers should use an ABN, ABN policies, how to properly complete an ABN and ABN modifiers.

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Question:

Is it possible to pre-determine Medicare benefits for surgical procedures?

Answer:

A CMS Final Rule published in the February 22, 2008, Federal Register makes eligible for prior determination - 'plastic and dental surgeries that may be covered by Medicare that have an average allowed charge of at least $1,000.' According to the Rule, contractors will have up to 45 days to respond to the requestor, 'taking into consideration the beneficiary's physical condition, urgency of treatment and the availability of necessary documentation.' This Rule stems from the Medicare Prescription Drug, Improvement and Modernization Act of 2003, which required a "prior determination process" by which physicians and beneficiaries may determine whether Medicare covers certain services prior to the provision of those services. This new process may affect the current ABN process. For a list of eligible procedures and detailed instructions on how to request prior approval, OMSs should visit their local Medicare carrier's website.

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Question:

What are the incentives/bonuses for participating in the E-prescribing program?

Answer:

There is no need to register to participate in the incentive program. To be eligible to receive an incentive payment, the e-prescribing measures above must be reported for at least 50% of the Medicare part B patients for whom you billed one of the CPT or HCPCS G-codes denominators appearing on page 2 of the 2009 Electronic Prescribing Incentive Program Specifications and at least 10% of total Medicare allowed charges are from these covered services. The bonus payment available to successful e-prescribers for 2009-2010 reporting is 2%; for 2011-2012 is 1%; and for 2013 is 0.5%. Beginning with the 2012 reporting period unsuccessful e-prescribers will actually see a payment reduction of 1%; 1.5% for 2013 and 2% for 2014 and each year thereafter.

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Question:

Can our office opt-out of traditional Medicare without opting out of Medicare Advantage/Medicare Managed Care plans? Also, if we are contracted with Medicare and not contracted with any of the replacement plans, what is my obligation in terms of Medicare fee schedule/patient responsibility, etc?

Answer:

When opted out of traditional Medicare, physicians are not entitled to Medicare or Medicare Advantage (MA) reimbursement. It is the traditional local Medicare carrier's responsibility to notify the MA plans that the doctor has opted out. If opted out of traditional Medicare you would have to privately contract with MA patients as well.

If one remains a Medicare provider and is not contracted with a Medicare Advantage (MA) plan, the doctor may possibly be prohibited from treating MA patients or from collecting more than the traditional Medicare private fee-for-service allowed amount. For instance, patients covered by Medicare HMOs are restricted to physicians within the MA HMO network. Patients covered by Medicare PPOs may see any physician they like, however some incur higher out-of-pocket expenses if they see a physician out of the network. Some Medicare PPO's may reimburse non-contracting providers only the original Medicare rate.

Medicare Advantage fee-for-service plans are permitted to establish their own fee-schedules and balance-billing rules, which, in some cases, differ from original Medicare payment rates and balance-billing rules. There are no formal provider contracts with MA fee-for-service plans, therefore if an OMS knowingly treats a MA fee-for-service patient, the OMS may be considered a "deemed" provider. Meaning the payment would be similar to that of the payment for traditional Medicare fee schedule for participating and non-participating providers.

OMSs treating enrollees of a MA plan will need to carefully examine the type of MA plan as well as the fee-schedule and balance billing rules with each plan to decide if the terms and conditions of participation warrant a decision to treat and be "deemed" a contracting provider.

Finally, if an OMS is not enrolled in traditional Medicare, he or she may not treat MA patients since Medicare Advantage is a Medicare product. It is advised that those OMS who take emergency call enroll in Medicare for the purpose of receiving an active provider number to obtain Medicare or MA reimbursement for emergency services rendered.

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Question:

I have recently become aware of a new Medicare rule that requires all providers who order/refer items/services for Medicare patients to have current enrollment records in Medicare. It is my understanding that a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record containing the provider's NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected. I am opted out of the Medicare program. How will this new rule affect opted out providers?

Answer:

Buried among the latest guidance in special edition MLN Matters SE1011 are references to dentists, opted out providers, the Advance Beneficiary Notice for Non-coverage (ABN) and a statement regarding due diligence by billing providers. OMSs that have opted out of Medicare may still order items or services for Medicare beneficiaries. Their opt-out information must be current (an affidavit must be completed every 2 years, and the NPI is required on the affidavit). Opt-out practitioners whose affidavits are current should have enrollment records in PECOS that contain their NPIs. For more information visit the Medicare Enrollment page of the AAOMS web site.

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Question:

What is E-Prescribing?

Answer:

E- prescribing is the prescriber's ability to electronically send an accurate, error-free and understandable prescription directly to a pharmacy from the point-of-care via a PDA (i.e., PalmPilot, Pocket PC device), desktop computer, or cell phone. E-prescribing is an important element in helping to improve the quality of patient care. The role of e-prescribing is to help reduce medication errors and patient safety.

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Question:

What type of Electronic Prescribing System will my office need to participate in the E-Prescribing Incentive Program?

Answer:

Eligible professionals must have adopted a "qualified" e-prescribing system. There are two types of systems: a system for e-prescribing only (stand-alone) or an electronic health record (EHR system) with e-prescribing functionality. Regardless of the type of system used, to be considered "qualified" it must be based on ALL of the following capabilities:

  • Generating a complete active medication list incorporating electronic data received from applicable pharmacies and benefit managers (PBMs) if available

  • Selecting medications, printing prescriptions, electronically transmitting prescriptions, and conducting all drug alerts

  • Providing information related to lower cost, therapeutically appropriate alternatives (if any) (the capability of an e-prescribing system to receive tiered formulary information, if available, would meet this requirement for 2009)

  • Providing information on formulary or tiered formulary medications, patient eligibility, and authorization requirements received electronically from the patient's drug plan, if available

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Question:

What constitutes an "eligible professional" to participate in the E-Prescribing Program?

Answer:

Under the E-Prescribing Incentive Program, covered professional services are those paid under the Medicare Physician Fee Schedule (PFS). To the extent that eligible professionals are providing services which are paid under the PFS, those services are eligible for E-Prescribing Incentive Program.

Note: Eligible professionals must have prescribing authority in order to participate in this incentive program.

To view a detailed list of eligible professions you can visit the CMS website.

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Question:

Will I be penalized for not participating in the E-Prescribing Incentive Program?

Answer:

Participation in the PQRI and/or E-Prescribing programs is currently optional; however beginning in 2012 those unsuccessful with e-prescribing will see a reduction in payment. It is possible the PQRI program may also become mandatory in the future where those not participating may be subject to Medicare payment reductions. Early participation will provide an OMS experience with reporting quality and e-prescribing data and if done successfully, result in additional reimbursement.

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Question:

What are the measures that OMSs can report to qualify for E-Prescribing Incentive Program?

Answer:

The following HCPCS G codes are available for reporting the e-prescribing measure:

G8443 All prescriptions created during encounter generated using a qualified e-Prescribing system

G8445 No prescriptions generated during encounter. Provider does have access to a qualified e-Prescribing system

G8446 Some or all prescriptions generated during encounter were handwritten or phoned in due to one of the following: required by state law, patient request, qualified e-Prescribing system being temporarily inoperable, or they were for narcotics or other controlled substance.

Note: A complete list of performance measures and associated codes is currently available in Appendix Hof the current CPT Coding Manual as well as on the CMS website.

For more information on the measures for e-prescribing visit http://www.cms.hhs.gov/ERxIncentive/06_E-Prescribing_Measure.asp.

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Question:

Medicare and some third party payers are not reimbursing for my general anesthesia services rendered at the same time as procedures such as extractions, biopsies, or treatment of fractures. They are stating that the service is inherent to the procedure therefore cannot bill the patient. What can I do?

Answer:

The bundling of anesthesia services is among the AAOMS' top advocacy issues. Medicare has established a national coverage decision considering payment for anesthesia services bundled with the payment for surgical procedures when administered by the operating surgeon. Unfortunately, Medicare sets policy trends in which third party payers often adopt and utilize for their own coverage determinations, therefore, prohibiting you from separately billing for or collecting payment for general anesthesia or moderate sedation.

As of January 1, 2006, CPT included six new CPT codes to report moderate sedation, three of which indicate the same physician is rendered both the moderate sedation and surgical procedure. There is also a list of CPT codes in Appendix G of the CPT Coding Manual, in which moderate sedation is inherent to the procedure, meaning that the payment for moderate sedation is included with the payment for the surgical procedure. The AAOMS was involved with the development of the new moderate sedation codes and assured that there was no OMS procedure codes included in Appendix G.

The new moderate sedation codes and the exclusion of OMS codes from Appendix G are positive results of our advocacy efforts and are used by the AAOMS to advocate for separate reimbursement for anesthesia services. Additional arguments include the scope of OMS practice and the cost effectiveness associated with performing certain procedures requiring general anesthesia in the office versus the hospital setting. For more information see the AAOMS Position Statement on the Bundling of Anesthesia Services.

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Question:

How do I determine whether medical insurance or dental insurance is primary?

Answer:

There is no rule of thumb to follow when coordinating medical and dental benefits. It varies among carriers and procedures. It is recommended to verify benefits beforehand as some dental and medical carriers will coordinate benefits. Recently, there have been many dental carriers requesting claims to be processed under medical first, even when the procedure is not covered by medical. In the event that the two carriers do not coordinate benefits choosing which to bill first can rely on the nature of the procedure or perhaps the benefits used. For instance, in cases of an oral cancer evaluation it may be best to bill medical first as dental benefit limits can be reached much quicker than medical benefit limits. For additional tips and information see Coordination of Benefits.

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Question:

How do I determine which parent's insurance is primary when the patient is covered by both parent's plan and the parents are divorced?

Answer:

Many times, the parent who is financially responsible for the child and the child's health care may not be the same parent that presents the child for care, which makes it very tricky when determining whose benefits are primary. There are two issues to take into consideration when determining benefits of parents who are divorced or separated: 1) Which parent has custody of the child and 2) The provisions of the divorce decree.

It is imperative to become familiar with your state coordination of benefits law. There are several states that have adopted a "joint custody" rule. When joint custody has been awarded, divorce decrees usually do not address order of benefit determination, therefore when dual coverage exists, the birthday rule may be used to determine which parent's insurance plan is primary.

On the other hand, when joint custody has not been awarded the divorce decree may state which parent is responsible for the child's health care expenses and that parent's health plan has knowledge of those terms, therefore agrees to be the primary plan.

Establishing an office policy addressing these issues will assist your office staff when they face these often-challenging experiences. For instance, if a child presents with the custodial parent but not the financially responsible parent, you may decide not to get in the middle and notify the parent at the visit that the treatment may only be rendered when the co-payment and deductible or other determined amount is paid. While it may not put you in a favorable position with the parent, your financial risk is too great not to have a firm policy in place.

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Question:

I am contracted with both of my patient's insurance plans. I wrote off the contractual discount indicated by the primary insurance then submitted the claim to the secondary insurance. However it appears the secondary insurance did not coordinate benefits with the primary as the payment from the secondary insurance exceeds the remaining balance? Can I keep the money?

Answer:

First, make the attempt to refund the overpayment to the secondary insurance. In actuality, the physician is not entitled to more than what was contractually allowed by the primary insurance. To accept more would be considered a contract violation. In the event the secondary insurance refuses to accept the refund because they in fact do not coordinate benefits, you may review your contract with the primary payer. Some contracts are written so that physicians may accept reimbursement exceeding the contractual allowed amount as long as the overpayment is received by another insurance carrier and not the beneficiary. If that is the case, you may readjust your charge and post the payment. If not, regardless of what the total amount collected by all insurances involved, you may only collect up to 100% of the primary carrier's allowed amount. Therefore, if there is a credit, you must refund the secondary insurance carrier or notify the carrier that the refund will be issued to the patient in the event the secondary carrier refuses the refund.

Note: Group plans and individually purchased policies usually do not coordinate benefits. In such cases, it is not rare for both to pay as if they were primary. When a patient is covered by an employer group policy and an individual policy, it is quite possible that the patient will make a profit.

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Question:

Is it legal to provide professional courtesy or discounts to my referring physicians and their families or staff?

Answer:

While the concept of providing professional courtesy may be a nice gesture and a long-standing tradition, the ramifications should be seriously considered. The mere act of providing a discount to certain patients is not in and of itself likely to raise charges of fraud, it is how or when the discount is being provided that is likely to get a physician in trouble, especially when they are not following insurance contract guidelines.

Waiving a co-payment or deductible may be considered a false claim by government agencies and third-party payers. Such a waiver may also be considered a violation of a managed care contract. Payers may view the waiver as a false claim since the actual charge was misrepresented when the remaining balance is forgiven.

Furthermore, offering incentives or remuneration to induce referrals is a violation of the Anti Kickback Statue and the False Claims Act. The Office of Inspector General encourages billing companies and providers to make a good-faith effort to collect co-payments, deductibles and non-covered services from federally and privately-insured patients.

Furthermore, the Stark II law, released in March 2004, further clarified the provision of free or discounted healthcare items or services to a physician or his/or her family or staff. For guidance with regards to properly handling professional courtesy or discounts see Professional Courtesy/Insurance Only.

In addition to these legal considerations, OMSs have ethical obligations under the AAOMS Code of Professional Conduct related to waiver of co-payments and deductibles. Section H.2.02 states "an oral and maxillofacial surgeon who accepts a payment from a third party, as payment in full without disclosing to the third party that the patient's portion will not be collected is engaged in over-billing." Thus to avoid ethical and possible legal ramifications, an OMS who wishes to waive or discount a patient's balance should notify the insurance carrier as well.

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Question:

The insurance carrier is denying orthognathic surgery stating the procedure is not medically necessary. What can I do?

Answer:

The first step in the appeal process is to determine the specific language used for the patient's benefit coverage for orthognathic surgery or oral and maxillofacial surgery. This will assist you in identifying the specific reason for denial of the procedure, e.g., lack of medical necessity based on whose guidelines, or specific exclusion clause.

Once you have determined that the plan does allow coverage for orthognathic surgery you can structure the appeal toward any deformity and stress the functional impairment(s) experienced by the patient such as pain and discomfort, or difficulty speaking or chewing. The AAOMS Guidelines to the Evaluation of Impairment of the Oral and Maxillofacial Region can assist you in providing a quantifiable analysis of the impairment.

You should also provide a carefully dictated clinical evaluation defining and quantifying the functional impairment. All supporting documentation of the functional deformity should be included (X-rays, photographs, and models). It may also be helpful to provide documentation of any existing pathology that is the result of the deformities (e.g., airway compromise, sleep apnea, speech pathology, periodontal disease, etc.) If the procedure is needed as a result of an accident, the date and type of injury should be documented.

When submitting an appeal, you may request a qualified oral and maxillofacial surgeon to review the case who is experienced and competent in the contemporary management of patients with these deformities.

You may be interested in utilizing sample letters written by AAOMS staff which provides appeal language that is often helpful in reversing insurance carrier determinations. These sample letters may be found in the AAOMS Insurance Manual: A Guide to Understanding, Filing, and Appealing Claims.

The following documents may also be helpful in supporting the medical necessity of orthognathic surgery:

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Question:

A carrier that I am contracted with told me that I can only charge a patient the contracted fee for a dental implant that was not covered by their medical insurance. Am I obligated to accept and charge the patient the carrier's discounted fee for noncovered services?

Answer:

The answer to this question ultimately comes down to the provider contract(s) with the carrier(s) with whom the doctor participates. There are some contracts that are so worded that the provider is prohibited from collecting more than the carrier's contracted allowed amount even for excluded procedures. By signing a contract containing such language the provider has agreed to the participating fee schedule amount for non-covered services. As far as being obligated to submit the claim, many providers may be under a contractual obligation to submit the claim for non-covered items if the patient requests them to do so. At the same time, the patient may choose to submit the claim on his/her own behalf. In either case, or even if the claim is not submitted, the provider is still contractually bound to accept no more than the carrier established fee.

If after reviewing his/her contracts, a provider finds that he/she has agreed to such terms, the provider can attempt to have the contract amended to remove this stipulation. Until the contract can be successfully renegotiated or is no longer in effect, the provider would be contractually obligated to accept the participating provider amount. If, however, a provider's contract does not prohibit billing more than the carrier allowed amount for excluded services, the provider can collect his/her usual fee from the patient. Below, please find links to both the AMA and ADA model managed care contract language from each of their web sites. These documents may be helpful to providers in the midst of contract negotiation.

» http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/claims-revenue-cycle/managed-care-contracting.page
» https://www.ada.org/members/sections/professionalResources/mod_contract_thirdparty.pdf

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