Implications if Medicare Expands to Cover Dental Services

Significant changes could be coming to dentistry if dental benefits are added to Medicare. A proposal, currently before Congress as part of a large budget bill, would do just that. If this proposal becomes law and Medicare begins to cover dental benefits, it would likely have major implications on the practice of dentistry, both administratively and financially.

While some Medicare Part C (Medicare Advantage) plans cover dental benefits, original Medicare, which is administered in a very different manner, does not. While Medicare Part C plans are administered by private insurers, original Medicare is administered by a myriad of federal contractors that are overseen by the Centers for Medicare & Medicaid Services (CMS). For dental providers accustomed to dealing with private insurers and Part C plans, interacting with Medicare may present new challenges. An experienced healthcare attorney can be key to navigating the regulatory and business challenges of Medicare compliance.

First, dental practices would likely come under the purview of the Medicare contractors. These contractors handle Medicare enrollments, claims processing, data analysis, audit and claims review, program integrity, and a myriad of other functions. Some decisions regarding Medicare-enrolled providers are made by contractors and some by CMS, although it is not always clear. Most decisions, including enrollment decisions and claims denials, are subject to a multi-level appeal process. Dental practices familiar with the business motivations of private insurers may be surprised by the sometimes-uncompromising nature of decisions made by CMS and its contractors. For example, unlike an overpayment demand by a private insurer, a Medicare overpayment demand can rarely be negotiated.

Lastly, if Medicare covers dental services, dentists will need to increase their awareness of the Physician Self-Referral Law (Stark Law) and the Anti-Kickback Statute (AKS). The Stark Law prohibits physicians from referring certain designated health services payable by Medicare or Medicaid to any entity with which the physician has a financial relationship unless an exception is met. Similarly, the AKS provides criminal penalties for individuals or entities who knowingly or willfully offer, pay, solicit, or receive remuneration in order to induce business payable by Medicare or Medicaid. While dentists are currently included in the Stark Law’s definition of a “physician,” both the Stark Law and AKS currently only apply to services payable by Medicare or Medicaid. If Medicare begins to cover dental services, the breadth of the Stark Law and AKS will likely widen and apply to dental services as well. Further, Congress or the Department of Health and Human Services (HHS) may change these statutes to further restrict dental practices.

For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.