Medicare Money Program2021-03-31T14:25:36-04:00

Medicare Money Program™

A huge moat has been built around Medicare, such that most people–including dentists–believe that Medicare has nothing to do with dentistry. They think that Medicare is only for medical procedures.

You should thank your lucky stars that almost everyone thinks that way–because there is a hidden strong bridge over that moat and it’s called the Medicare Money Program. It is the roadmap that some dentists follow to get paid by Medicare for as much as 25% to 50% of total treatment plan cost.

You may be full of questions about how it’s possible to be paid through Medicare how could so many people  be mistaken about the program?

I have an FAQ below that answers many questions doctors have asked. Before we get into those questions, I thought it may be helpful to outline what you can expect when you are part of the Medicare Money Program™:

  • We are the largest network of Medicare implant-focused participants in the US.
  • Across our user network the range of final results for those routinely advertising and who adhere to our sales process as taught are often $100K in additional 1040 income. Some members have experienced multiple months of $500K/month Medicare-related production (Medicare claims + patient portions).
  • The credentialing process requires only about 90 days, sometimes less.
  • You can expect predictable payments: Average payment $6K per surgical visit subsidy for those with Original Part B + medical necessity. $12K minimum benefit for full-mouth cases. Some doctors have seen $20K and even $30K for a single patient. (Bulk of payment is from combination of bone graft, transitional appliance, CT scan, and surgical guide.)
  • Patients receive a subsidy on average of 25-50% of total treatment plan cost. Patients pay their estimated balance UP FRONT. Patients also pay the billing fee for claims.
  • 7 out of 10 patients who respond to our Medicare oral surgery/implant advertising have medical necessity and as such have a billable claim.
  • Claim turnaround time is 21 days on average.
  • No additional staff is required because we provide billing/coding service.
  • You receive comprehensive training in medical diagnosis and medical necessity documentation. We also provide clinical documentation coaching.
  • Some doctors with associates have reported that this is what tipped their practice into fully supporting both doctors.

Here is a more detailed FAQ to answer the most common questions:

Q: As an oral surgeon, I have been a Medicare provider forever and have not been able to bill anything other than pathology and occasionally trauma. Years ago, we tried to bill 21248 and 21249 with no result.2021-03-31T12:55:28-04:00

A: The issue lies in one of the following areas:

These codes are routinely payable but if you have tried to do the billing yourself, payment isn’t predictable.

2. See the previous discussion on this. It is in your best interest to swallow your pride and follow the lead of the medical surgeons who use expert third-party billers to get paid. It’s basically impossible to get paid without ongoing, expert, third-party help, especially in the wake of rule changes starting in 2020.

3. Not following administrative steps required by Medicare. This can be related to specific rules governing submissions in your MAC, improperly prepared compliance documents that upon submission to a CMS request result in a claim denial, and improper coding that also results in a denial. Unless an expert knowledgeable in how to navigate denials in your jurisdiction is working on your behalf, you will have a very limited chance of moving past claim denials.

Q: What kind of case volume will adding Medicare Oral Surgery/Implant advertising and billing bring to my practice?2021-03-31T12:56:46-04:00

A: 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.

Q: What’s the main reasons practices aren’t successful with Medicare claims?2021-03-31T12:57:11-04:00

A: First, it’s believing that they can do their own billing. If you want a sign of this, ask a few oral surgeons around your office. Its IMPOSSIBLE for dental office staff or oral surgery staff to stay on top of changes in claim-submission protocols that cause predictable claim payments. There are no billing courses on this subject, due to the relatively small volume of billings in this surgical niche compared to medical practices.

These same offices will say Medicare billing doesn’t work when the issue is that HOW THEY BILL doesn’t work. They try to push the blame onto the system versus where it belongs.

Now past the oral surgeon, ask an orthopedic surgeon or an ophthalmologist if they do their Medicare billing in-house and they will laugh you and ask if you are daft. These surgeons understand that it takes ongoing expertise for predictable claim payments.

Starting in 2020, new rule changes further restricted the number of entities having predictable billing success. Our members continue to have success while other implant practices are coming to us in an attempt to restart predictable billing.

The bottom line for this first group is that it is only the pros working full-time at this micro-billing niche are now successful at navigating the payment system and adapting to changes in local rules governing payments.

The second-biggest reason for being unsuccessful at Medicare claims is doctors fail to verify patient benefit eligibility before rendering treatment, and then after surgery discover the patient has no benefits.

Those adhering to the simple verification step and using our professional billing and coding company continue to have predictable success with payments from Original Part B and Medicare Advantage PPO plans.

Q: Do I need to be a member client of the Big Case Marketing Full-Arch Program to participate in the Medicare Money Program?2021-03-31T12:57:35-04:00

A: Yes. This Program is restricted to members only of our advertising program.

We find the best synergy in our advertising results and full-arch case flow when there is a mixture of fee-for-service advertising (not Medicare) with a second focus on Medicare oral surgery/implant advertising. This keeps your practices cases diversified without becoming over-reliant on one type of patient.

It is also limited with respect to how many practices can be accepted for credentialing in any given market area. Once a market area has reached capacity, we close it to new participants and a waiting list forms. We do reserve the right to fire participants if they are not running advertisements to the public or are not submitting claims. Part of our mental reward with our years of effort to create this mechanism for implant practices to make implants more affordable for Medicare patients is that we want what we have brought to the profession to be put use helping patients!

If we go to the effort to help you, we expect that you do your part to help more patients.

Q: Have any of your Program members ever been audited by Medicare?2021-03-31T12:58:01-04:00

A: 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.

Q: How many practices currently successfully submit and receive claims from the Medicare Money Program?2021-03-31T12:58:26-04:00

A: 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. To determine of your market area is available, go [here].

Q: Will we know before treatment begins what Medicare will pay?2021-03-31T12:58:54-04:00

A: 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.

Q: Is each claim sent in for approval (pre-authorization) prior to performing treatment?2021-03-31T12:59:26-04:00

A: Medicare Original Part B does not require pre-authorizations, and as such, claims are paid based off the Medicare Fee Schedule. Medicare pays 80% of the Fee Schedule and 20% is picked up by the patient’s supplemental insurance. If the patient does not have supplemental insurance, then the patient is liable for the additional 20%.

For Medicare Advantage PPO patients, a predetermination is required which is not complicated and once you have an approval for the pre-determination, the payment is guaranteed. Ninety percent of pre-authorizations are approved. The claim monies for these patients are sufficient enough that they are calling you to ask about when they start treatment!

Q: Can you do my DME for Sleep Apnea?2021-03-31T13:00:10-04:00

A: Yes, in fact, we will do it for free as part of our fast-track credentialing.

Q: After I’m credentialed, how long does it take to start getting claims paid?2021-03-31T13:00:44-04:00

A: Our fast-track protocols allow for most of our new members to be credentialed and ready to submit claims in 30 days or less. Following credential approval, there is an additional 14-21 days to set-up EDI for your practice.

Following EDI approval, claim submission to payment times average less than 21 days.

New members need a minimum of 30-60 days for learning how to differentiate medical necessity, compliance documentation, as well as to on-board with our preferred billing company for using their time-saving, secure-provider platform that serves as your claim-processing hub.

Q: Do you also pursue private medical-insurance claims?2021-03-31T13:02:36-04:00

A: Yes and no. We only pursue Medicare reimbursement and then private secondary insurance when the primary insurance is Medicare. If a patient has only private pay, we do not pursue those claims.

The outliers beyond Medicare which are workers’ compensation and personal injury. These claims which we refer to as whales can be $50K and more in size but take substantially more investment in time and overhead. Due to the upfront investment, we only recommend taking on a few of those cases annually. Additionally, the whale case is best for those clinicians who are detailed masters. Documentation for these claims requires the most detail of any clinical work. If you are in this category of attention to detail and are billing a reasonable volume of Medicare Part B claims, we can talk further about the approach to pursuing these patients and claims.

Q: What are some typical reimbursements for qualified Medicare patients as part of this program?2021-03-31T13:03:00-04:00

A: The per-arch reimbursement most often includes the Medicare Part 1, exam, OPG, CT and Medicare Part 2 surgery, BG, TBS (in 40 states and territories), and osteotomies.

This routinely results in a $4,500-$8,000 payment for each arch depending on exact clinical conditions, codes required for that patient, as well as whether the patient has a supplemental (secondary) policy covering co-pays.

For an average removable on locator case, this claim payment will offset the patient’s total treatment cost per arch by 40-60%. For a fixed zirconia case, the offset is from 20 to 30% depending on restorative fees. Under either scenario, these patients readily choose those who can submit and obtain their benefits versus a provider who can’t, or who refuses to do so.

Q: Can you guarantee that we will get Medicare claims paid?2021-03-31T13:03:25-04:00

A: Yes. To get your claims paid predictably it is mandatory to use our preferred billing and claim submission company. It is imperative that you follow the clinical advisement on what constitutes medical necessity. We provide access to a team who will get you approved for billing inside the Medicare system, train you in medical-necessity diagnosis, and teach current compliance-documentation standards.

If you follow our protocols and advice, we guarantee that at least 98% of your claims are paid.

We also can guarantee a flow of Medicare patients when we place our proven advertisements exclusively to Medicare Money Program participating members.

Q: Does it matter if I’m a generalist or a specialist?2021-03-31T13:03:54-04:00

A: No. Medicare makes no distinction between the two when it comes to claims being paid. Both can expect the same results in the program.

Practices benefiting the most are those who perform both the surgical and restorative aspect of the case either by the treating physician dentist (implantologist model) or by way of an in-house team (ClearChoice model).

Those who only perform the surgical aspect, who are not willing to adapt to what patients want today, do not benefit. If you are a traditional specialist and want to benefit, we will work with you on having an in-house restoring doctor so you can benefit.

If you are an implantologist, you stand to benefit the most and the fastest. If you happen to have special clinical designations (Fellow, Associate Fellow, or Diplomate), you will benefit even further.

Q: I’ve heard that Medicare only covers bone grafting. Isn’t this true?2021-03-31T13:05:05-04:00

A: Medicare covers medically necessary SURGERY PROCEDURES. Limiting this question to the head and neck, there are numerous covered oral surgery procedures. Additionally, CBCT interpretation and exams are billable.

Due to what is called tiered down reimbursement, generally bone grafting is the focus of claims since that is where your patient will receive the most benefit from their coverage.

When one considers that a dental bone graft under the very best dental insurance plan is reimbursed at $500-$600 while a bone graft under the patients Medicare Part B or Medicare Advantage PPO policy is paid at $4500-$5500, it makes clinical and financial sense to treat that patient under their Medicare plan.

Because coding and claim submission protocols change often in the Medicare system and those changes are not universal across the 12 administrative jurisdictions, only the most competent billing and claim submission company adapting to local coverage guidelines can provide the most predictability in reimbursement, so you and your patients can predictably continue to see payments that offset total costs by 25-50%.

Q: What constitutes Medical Necessity?2021-03-31T13:05:30-04:00

A: 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.

Q: Are claim denials common?2021-03-31T13:06:27-04:00

A: It depends on the people you work with.

With many billing companies who only dabble in medical necessity oral surgery claims, denials are quite common and in fact those stories are what circulates among implantologists and oral surgeons. Who bills for you matter a lot when it comes to the outcome for payment!

Nationally there are 2-3 billing companies that continue to evolve with CMS processing guideline changes across ALL 12 Medicare jurisdictions to avoid denials.

With our preferred-billing company servicing our member implant dentists, denials are rare. When a denial occurs, they almost never lose on an appeal and the claim moves on to being paid. Thus, our doctors get paid predictably, year after year.

Q: How many dentists are now credentialed as Medicare Part B providers?2021-03-31T13:07:03-04:00

A: Fewer than 1% of dentists in the United States are Medicare Part B or Medicare Advantage PPO providers credentialed (certified) to treat Medicare patients under these plans. Fewer than 0.1% of implant focused dentists in the US are credentialed and available to service 61 million Medicare patients.

Virtually no competition exists among providers for the full-arch Medicare patient wanting to use their coverage offset their total reconstructive treatment costs by 25-50%.

Q: What services will Medicare not pay for?2021-03-31T13:08:04-04:00

A: Medicare Part B claims filed on a medical credential will NOT pay for any of the following:

  • Any dental appliance
  • Crowns, fillings
  • Preventive treatment
  • Periodontal treatment
  • Gingival surgery
  • Non-hospital-based anesthesia
  • Extractions or Alveoplasty
  • Implants (a minor benefit in 40 states/territories and no benefit in 16 others)
  • Membranes or screws
  • Wellness care
  • Hormone replacement therapy
  • Weight-loss treatment
Q: What services can be predictably billed and paid by Medicare Part B or a Medicare Advantage PPO Plan for patients with the correct medical coding, diagnosis, and claim submission?2021-03-31T13:08:27-04:00

A: Services in a non-hospital environment include:

  • Bone grafting/bone reconstruction
  • Osteotomies
  • New patient exams, established patient exams
  • OPG, CBCT interpretation
  • Endosteal implants (minor benefit in 33 states and US territories)
  • Sleep apnea devices (with DME credential)
  • Botox for MFPD
  • TMJ treatment

The most money coming from Medicare that helps your patients is related to bone manipulation/stabilization and grafting procedures. Our biller coders will look at each case and determine which codes and combination of codes to file for the best possible reimbursement for your case. The most natural add-on service from the list above is apnea appliances for patients with that condition who are also having implant therapy.

Q: What type of services do I need to perform to benefit from the Medicare Money Program?2021-03-31T13:09:19-04:00

A: To Participate in the Medicare Money Program and to benefit from Medicare Part B Medical billing or Medicare Advantage PPO Medical billing, you (or another doctor in-house, be that an associate or 1099 contractor) must perform full-mouth extractions, quadrant or full-arch bone grafting, and place dental implants at your facility. If you do not perform these services, this program is not for your practice. If you place only single-tooth implants, this program is also not for you. General practice dental services, preventative, and dental restorations are not reimbursed via Medicare Part B.

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