The Business of Medicare: Why Ignoring Medicare is Not an Option for Dental Practices

In this day and age, the lines between medical and dental care are blurring more than ever. Dental professionals are faced with a significant compliance hurdle that many don’t even know exists – Medicare’s Mandatory Filing Law.

While the Mandatory Filing Law has been in effect for over 30 years, it remains a highly misunderstood Medicare regulation in the dental industry. With CMS expanding coverage for “inextricably linked” dental services in recent years, the risk of non-compliance is no longer theoretical, but a daily reality for dental practices.

Simply stating “We don’t take Medicare” is not sufficient.

Since September 1, 1990, Section 1848 (g)(4)(A) of the Social Security Act has required all healthcare providers—including dentists—to file Medicare claims for any procedure that Medicare potentially covers. Many dentists operate under the misconception that a simple verbal statement such as “we don’t take Medicare” is enough to opt out of the system. Unfortunately, this is not the case and hasn’t been for many years. Medicare does not consider verbal notification to patients sufficient and actively monitors compliance.

Ignoring this law can have devastating consequences for your practice. These include:

• Requirement to refund the patient
• Financial penalties of up to $2,000 per violation
• A misdemeanor conviction, additional fines, and even potential jail time
• Being excluded or debarred from Medicare (and potentially all federal healthcare programs) 

Are there exceptions to this law?

Yes. While the law seems strict, there are specific scenarios where you are exempt from the mandatory filing requirement. Some of these scenario exceptions are listed below:

Scenario 1: The service is not covered.

Scenario 2: The provider has formally opted out of Medicare and has entered into a signed private contract with the beneficiary before the start of treatment. (see below for a clinical example)

Scenario 3: The services were furnished outside of the United States.

Clinical example:

Mrs. Ramirez, a 72-year-old on Original Medicare, needs heart valve replacement surgery. Before proceeding with the procedure, her cardiologist requires a dental clearance to ensure no oral infections could cause endocarditis. Upon the evaluation from the provider, it is determined that tooth #15 should be extracted prior to surgery due to a periapical abscess and advanced periodontal disease.

The provider has a current Medicare opt-out affidavit on file with their Medicare Administrative Contractor (MAC). The provider explains to Mrs. Ramirez that Medicare will not pay for the extraction since they have opted out of Medicare. Mrs. Ramirez will sign a private contract acknowledging that she is responsible for the full office fee for the service and that a claim is prohibited from being sent to Medicare for reimbursement.

The extraction is completed, and a letter of clearance is then provided to her cardiologist. Since the provider has formally opted out, the provider is not in violation of the Mandatory Filing Law.

Keep in mind that in each of the above three scenarios, if a patient requests that a claim be filed to their plan and you refuse, the beneficiary can file Form 1490S directly with the Medicare Administrative Contractor (MAC). This will then trigger a review of the provider’s status with Medicare. If the provider has not formally enrolled or opted out, Medicare may force a refund to the patient and levy additional penalties to the provider.

If your plan is to receive payment and stay compliant, you must treat Medicare as a federal program with strict, non-negotiable rules.

Simply avoiding Medicare is no longer a viable strategy for dental practices. The Mandatory Filing Law is a federal requirement with significant financial and legal implications. As Medicare continues to expand its reach into the dental chair through “inextricably linked” services, the “ignorance is bliss” approach to billing is no longer a feasible business strategy. By fully understanding the mandatory filing law you protect your practice from costly penalties and, more importantly, provide your patients with the transparency and care they deserve. Take the time now to review your office protocols for Medicare and update these protocols if necessary. A little administrative diligence today can prevent a major compliance headache tomorrow.

For more on Medicare, see the 30-page section on Medicare in our 2026 publication of Dental Administration with Confidence.

Source:

Practice Booster (2026). Dental Administration with Confidence (pp. 135-136). 2025 eAssist Publishing, LLC.