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Washington State Dental Association

Dr. Mary Jennings' Editorial: Making my Eyes Twitch!

Every now and then a policy comes through that is so irritating that it makes my eyes twitch. The latest one comes from Medicare. Like most irritating policies, it was created with the best of intentions.

The Affordable Care Act (ACA) changed the healthcare playing field in many ways. Several government agencies are struggling to write rules to fit this new act. One of the drivers for the creation of these new rules is cutting the costs created by fraud. 

A few months ago, the Centers for Medicare and Medicaid Services (CMS) asked the American Dental Association (ADA) and others to comment on rules it was creating for Medicare. Included in the rules was a proposal that would require providers who write prescriptions covered under Medicare Part D be enrolled or have formally “Opted out” of Medicare. Heretofore, Medicare honored the prescriptions written by non-registered providers for their Medicare patients. The fact that the patient was enrolled and needed medication seemed to be justification enough. Evidently, there was abuse of this system. So here we are. After the June 1, 2015 grace period, neither pharmacies nor patients will be reimbursed for any prescription a non-enrolled prescriber writes, unless the prescriber has opted out. 

In real life, that means that if you have no Medicare patients, you have no worries. The rest of us have to decide if it is less painful and more ethical to enroll (or opt-out) and help our Medicare patients, or not act and suffer their wrath.

I understand what enrolling in Medicare is. If you look for the forms online it is overwhelming. While much of it may be explanatory information, the Medicare enrollment form is 29 pages long. On the other hand, the “Opt-Out Affidavit” option is only two pages, although it has to be resubmitted every two years. Opting out verifies us as legitimate practitioners and our prescriptions are covered. Enrolled practitioners can bill Medicare while practitioners who opt out cannot. Probably the best way to opt out for dentists is to fill out the “Ordering and Referring Form” since it is only thirteen pages and only has to be submitted once. The ADA, working with CMS, helped develop it several years ago as an alternative to the longer enrollment form. 

These changes caused hell amongst the yearlings (i.e. those of us who were perfectly content with the old system. The system most of us never billed and never had to bother belonging to.) The ADA pointed out that it was insensible and burdensome for the roughly 194,000 dentists in the United States to register for Medicare. The ADA argued that registering dentists will not stop fraud and abuse because prescriptions written by dentists represent a tiny fraction of the Medicare prescription budget, administrative oversight would be costly, and it is simply not necessary. We all know that it would be problematic for Medicare patients who live on fixed incomes to pay out of pocket for prescriptions written by dentists. 

At one point, CMS withdrew the rule and we felt relieved. It was short lived. The final rule was issued on May 23, 2014. Despite our best efforts, registration of dentists was included. The effective date for the rule is July 22, 2014 with a June 1, 2015 grace period.

In response to objections from the ADA and others, CMS responded by saying: “While we recognize the concern of these commenters, we do not believe dentists, psychiatrists, VA physicians, or eligible professionals should be granted special exemptions from 423.120. The issue of primary concern to us is not the typical volume of drugs these individuals prescribe but the need to ensure and confirm that Medicare payments are only made for Part D drugs that are prescribed by qualified physicians and eligible professionals.”

I feel like an innocent bystander caught up in this fray. It is not about us. We are a small percentage of the prescription writers and probably even a smaller percent of fraudulent providers. This is just another irritating thing we have to keep up with. With the exception of feeling good about helping our Medicare patients in need, there is no incentive for us to bother to enroll or opt-out. This rule makes an expensive program more expensive. Why do the good guys have to bear the burden instead of going after the creeps who forge prescriptions? What is that all about?

To the good, this rule is harsh enough that there are strong points to argue to legislators and budget watchers. The other professionals who are affected will be complaining too. The ADA is putting their sharp, collective minds together to quash this rule. To the bad, government agencies are pedantic and justice rides a slow horse. 

Looks like I am going to have to sharpen my #2 pencil and sign up next spring if we have not eliminated this irritating thing by then. Like most dentists, my patient’s needs come before my own. I still think we have a good chance at turning this around. I look forward to the fight. 
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