medicareWhen it comes to Medicare, most people (including dentists) are under the impression that it is only for medical procedures and has nothing to do with dentistry.

If more dentists knew about the Medicare Money Program, however, they would see that they can get paid as much as 25-50 percent of the total treatment plan cost for qualifying procedures.

How is this possible? How could so many people be mistaken about the Medicare Money Program?

The key is with dental implants. Let’s go over some of the most common questions related to Medicare and dental implants to help you see how Medicare can help your practice.

1. Will advertising Medicare for dental implants bring more patients to my practice?

When our members allow us to advertise the Medicare message as part of our full-arch advertising campaigns, they see an increase in case volume from 50 to 100%. The variation is related to how closely they follow our case-presentation and phone-consult protocols. Those who adhere the most closely to our protocols as teams see a doubling in cases.

Another option for practices adhering to the case-presentation and phone-consult protocols are that they can reduce ad budgets while maintaining case volume. For some practices, this has resulted in a 50% reduction in ongoing advertising expense.

2. Is there a risk of being audited by Medicare?

As with any insurance plan you participate in, audits can happen. Fortunately, audits are rare. The educational training by way of our preferred billing company is designed to help identify the cases that fall under medical necessity which results in claims that are easily defendable.

To further reduce audit risk, our billing/coding specialists provide ongoing claim review to identify issues with compliance documentation. Annually, they will also look at a random sampling of your claims in depth, looking for holes in compliance.

By adhering to ongoing compliance recommendations, your risk will be lower than those without this level of oversight. Lastly, an insurance policy is made available to our members so that should an administrative audit happen, the appeals process will be handled by advisors with the longest experience in the industry at winning audits on appeal.

3. How many practices are able to participate in the Medicare Money Program?

Our provider count ranges in total numbers depending on many factors including retirement or practice-sell transitions. We have room for up to 200 program members in the U.S. and U.S. territories.

4. How will I know if Medicare will pay for a patient’s treatment?

You will not know exactly what is going to be covered by Medicare beforehand. However, the Medicare Fee Schedule is posted for every region which allows each of our members to predictability be within a few hundred dollars on any estimate you provide.

Additionally, once your team is fully onboarded with our preferred billing company, there is an estimator tool that will further refine your estimate.

Past the estimated benefit, you will charge and collect from the patient all of the dental-related treatment fees such as restorations which are 100% outside of the Medicare system and are not affected by your participation with Medicare.

You will make financial arrangements on the balance of your total treatment plan fee, just as you would with any fee-for-service patient. The power for working to obtain benefits for patients via their Medicare coverage is that the patient has a reduced out-of-pocket cost (25-50% less cost to the patient), while you are getting at least 100% of your total case fee.

For the practice this reduces the discounting pressure often resulting from local competitors seeking to treat these same patients. Your competitors who cannot bill Medicare are unable to discount their total case fees by 25-50% to compete with the final cost a patient pays out of pocket to your practice!

You will also know whether the patient has coverage for services. With our training and assistance, you will never start treatment without knowing that some coverage exists. Our experienced biller/coder will guide you throughout and make inquiries and appeals when needed.

5. Medicare is only available for ‘medical necessities.’ What qualifies as a medical necessity?

Oral disease is well documented in the medical literature to worsen many other systemic organ diseases. This includes heart disease where mouth infection can contribute to heart attack, thrombosis leading to stroke, and vascular and valvular infection. Mouth disease adds to the risk of pulmonary infection and can contribute to serious pneumonia. Patients with COPD are at great risk of pulmonary infections from mouth disease. Patients with diabetes are at great risk of infections in other parts of their body as well, because of bacteria from gum disease (pyorrhea).

The mouth is a main target of diabetic infection with poor healing. Patients with GERD and other GI issues experience many of these issues due to poor diet and being unable to choose healthy food groups for good nutrition. A recent study by the cancer society linked colon cancer to periodontal disease and chronic infections of the mouth.

If a patient has any of these conditions and radiolucencies beyond the apices of the teeth (an objective sign of infection), its likely they will qualify for Medical Necessity.

Generally, patients in a terminal dentition have objective sign of infection on radiographs which meets medical necessity guidelines. Terminal dentition patients now make up the majority of full-arch implant cases being treated.


Have more questions? Visit our Medicare Money Program page to read more questions, answers and statistics related to Medicare and dental implants.