Medicaid Dental Stakeholders
Meeting
July 27, 2012
Webinar Broadcast
• This presentation is broadcast as a visual
slideshow and audio output only
• Webinar attendance requires registration at:
Quarterly Dental Stakeholder Meeting
https://www2.gotomeeting.com/register/609542
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2
New Format for Stakeholders Meetings
• Stakeholder Meeting announcements are
posted on the HHSC website at:
http:www.hhsc.state.tx.us/meetings
• This presentation will be sent to the Federal
Government (CMS) as documentation of
today’s Agenda
• Stakeholder meetings are held Quarterly:
- next occurrence on October 26th, 2012
- 2013 in January, April, July, October
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New Format for Stakeholders Meetings
• All questions were submitted in advance at:
DentalStakeholdersMeeting@hhsc.state.tx.us
• A total of 13 emails with questions were
submitted to the inbox by July 23, 2012 and
are answered in this presentation
• Webinar archive of this meeting posted at:
http://www.hhsc.state.tx.us/news/WebBased_
present.asp
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After The Meeting
• Representatives from the DMO’s are
available at the rear of the room for 30
minutes after this presentation.
• They cannot answer specific claim questions
Introduction of Speakers
Managed Care Organization (MCO) Dental Directors
 Dr. Carlos Garcia, MCNA
 Dr. Monica Anderson, DentaQuest
 Dr. Shawneequa Harris, Delta Dental
State Agencies (HHSC, DSHS)
 Scott Schalchlin
 Susan Gibson
 Colleen Grace
 Rudy Villareal
 Dr. Linda Altenhoff
 Dr. John Roberts
Guest Speakers
• Texas State Board of Dental Examiners (TSBDE) – Lisa Jones
• Electronic Health Record Incentive Program (HHSC) – Julia Alejandre
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Texas Medicaid EHR Incentive Program:
Dentists
Julia Alejandre / Medicaid HIT Team
The Program in a Nutshell
• Incentives of up to $63,750 are available for the adoption
and meaningful use of certified electronic health record
(EHR) technology:
• AIU (Adopt, Implement, or Upgrade) in the first year of participation
• Meaningful Use (MU) in up to 5 subsequent participation years.
• Eligible Professionals (EPs) include dentists, along with 4 other
provider types.
• First year payment can be received in 2011 through 2016.
Final payment can be received up to 2021 for EPs.
• At least 50% of all encounters must be at a site or sites with
certified EHR technology.
8
Patient Volume Threshold
Payment Year by EP Type
Year 1 for most EPs
Years 2-6 for most EPs
Year 1 for pediatricians and pediatric
dentists
• Pediatric dentists are eligible for the
Medicaid
Patient
Volume *
30% or higher
Incentive
Amount
Max. cumulative
incentive
over 6 years
$21,250
$63,750
30% or higher
$8,500
20% to 30%
$14,167
lower patient volume threshold of 20%.
$42,500
Years 2-6 for pediatricians and pediatric
• Pediatric dentists attesting to 20-30% Medicaid patient volume will be
dentists
20% to 30%
$5,667
required to upload documentation that they are either board certified in
pediatric dentistry, or they completed a pediatric dentistry residency.
* If the EP practices predominantly in an FQHC or RHC,
patient volume threshold is 30% Needy Individual volume
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(Medicaid, CHIP, uncompensated care, sliding scale).
EPs: AIU and Stage 1
Requirements
• First year of program participation: Upload documentation that
shows AIU (purchase order, contract, or subscription)
• Stage 1 Meaningful Use:
• 20 MU measures – 15 from the “core set” and 5 of 10 from
“menu set”
• 6 Clinical Quality Measures (CQMs) – 3 Core or Alternate Core
plus 3 from list of clinical measures of the provider’s choice.
MU: Must include at least one
Public Health measure:
1) Immunizations
2) Reportable Labs
3) Syndromic Surveillance
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How to Register and Attest
1.
2.
3.
Register at CMS: https://ehrincentives.cms.gov.
Verify enrollment as a Texas Medicaid provider, with an active
TPI. If you assign payment to yourself, your SSN must be listed
in your TMHP profile.
Gather required information and documentation:
•
•
•
•
4.
EHR certification number.
Group or individual attestation choice.
Patient volume information (numerator and denominator).
AIU documentation.
Log into the portal and attest. Go to www.tmhp.com and log in.
Scroll down to “Manage Provider Account” and select “Texas
Medicaid EHR Incentive Program.”
For the full checklist of steps: Go to www.tmhp.com and select
Providers; go to the “Health IT” page and select “EHR Program
Information” from the list on the left; click on “Getting Started with EHR
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Incentive Program”
Additional Resources
•
•
•
•
•
•
•
Learn about the Texas Medicaid EHR Incentive Program through a selfguided e-learning tool: www.texasehrincentives.com.
Get technical assistance through the Regional Extension Centers at
www.txrecs.org.
Review program information on the CMS website:
http://www.cms.gov/ehrincentiveprograms/.
Review additional Texas Medicaid EHR Incentive Program information
at: (http://www.tmhp.com/Pages/HealthIT/HIT_EHR.aspx).
Learn about a recent study on EHRs and healthcare outcomes:
http://www.nejm.org/doi/full/10.1056/NEJMsa1102519.
Sign up for e-mail updates at
https://public.govdelivery.com/accounts/TXHHSC/subscriber/new and
enter your email address. On the subscription topics page, go to the
Projects section and select “Health Information Technology”.
Submit questions by sending an email to HealthIT@tmhp.com or calling
1-800-925-9126, option 4.
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New Format for Stakeholders Meetings
Questions to the Dental Directors were
submitted by Organized Dentistry:
• Texas Dental Association (TDA)
(single source for today’s presentations)
• Texas Academy of Pediatric Dentistry (TAPD)
• Texas Academy of General Dentistry (TAGD)
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Q: Tomina Vance
Have HHSC and the MCO's determined what they
are going to do about the bundling of fees? There
needs to be an increase in multisurface fees if you
are going to allow bundling.
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TMPPM Fee Schedule
•
•
•
•
2140
2150
2160
2161
-
$ 65.72
$ 87.46
$111.42
$ 60.04
•
•
•
•
2391
2392
2393
2394
- $84.08
- $110.20
- $101.18
- $75.06
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A: Multiple Surface Fillings
• It is appropriate (and required) that exact
restorations/surfaces are reported on the claim form
• For payment purposes the MCO’s are allowed to
administrate and combine contiguous surfaces
• HHSC does not dictate fees to the MCO’s
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HHSC Stakeholders Meeting
July 27, 2012
Sealants on Anterior Teeth
Per HHSC guidance, sealants on anterior teeth are a
Medicaid covered benefit and MCNA Dental is
reprocessing claims for anterior sealants.
Effective August 1, 2012, MCNA Dental will require a
Pre-Authorization on anterior sealants. The PreAuthorization request must include diagnostic
photographs of the anterior teeth and must specify the
tooth number and surface.
Bundling and Recoding
Bundling - MCNA Dental does and will continue to utilize bundling of
services. The bundling scenario that has been asked the most is regarding
one, two, three, and four surface restorations. In these cases, MCNA
Dental is bundling because there is no justification to identify multiple
restorations on a single tooth as independent restorations.
Re-Coding – MCNA Dental follows ADA and CDT Definitions and upon
review of Pre-Authorization and/or Claims documentation, to include x-rays
and rationale, our Dental Reviewers may not concur with CDT Code
submissions. Upon receipt of a CDT Code that is not clearly supported by
the Pre-Authorization, x-rays, and/or rationale submitted by a provider,
MCNA Dental will re-code to a CDT Code that more clearly reflects to the
submitted documentation. The Provider does have appeal rights regarding
re-coding of a procedure.
Provider Portal
TDA Question - The portal should include edits/audits features similar to those
available on the Texas Medicaid and Healthcare Partnership (TMHP) portal so that
dentists and their staff may immediately identify when incorrect or incomplete
information is being uploaded. This will increase the number of “clean claims.”
MCNA Dental recognizes the benefit for our Provider Portal to be as user friendly as
possible. As such, MCNA has already incorporated many edits and messages in our
Provider Portal that inform providers of invalid or incomplete information prior to the
submission of data.
MCNA welcomes any requests for enhancements to our Provider Portal from our
providers as well as from HHSC and TMHP.
MCNA will gladly incorporate additional edits/audits in our Provider Portal as are
available in TMHP's portal so long as TMHP made the description these edits/audits
available to us for review and implementation.
Amendments
TDA Question - Amendments to the agreements between the dentist and the dental
plans should only be done with the dentist’s written consent. This helps ensure that
the dentist provider clearly understands the change(s) to the agreement.
Article XI Miscellaneous, Section 7.
Amendment. This Agreement, including all Attachments, may be amended at any
time by mutual written agreement of the parties. This Agreement and any of its
Attachments may also be amended by MCNA furnishing Provider with any proposed
amendments. Unless Provider objects in writing to such amendment during the
thirty (30) day notice, Provider shall be deemed to have accepted the
amendment. Notwithstanding the foregoing, this Agreement shall be automatically
amended as necessary to comply with any applicable State or federal law or
regulation and applicable provision of the Payor Contract or State Contract.
Participating MCNA Dentists
TDA Question - How many active Medicaid and CHIP participating dentists, based
upon individual dental license numbers, does MCNA have in their provider
network?
MCNA Dental has 4,364 Medicaid participating dentists
MCNA Dental has 4,100 CHIP participating dentists
* These numbers may reflect access points and not individual licenses
TDA Question - How many individual orthodontists and appropriately qualified
general and pediatric dentists does MCNA have in their ortho provider network?
MCNA Dental has 592 Orthodontist access points, 361 General Dentists, and 39
Pediatric Dentists.
Medicaid Orthodontic Update
Continuance of Care
MCNA Dental is committed to the continuing care of all members. As part of this commitment,
MCNA will honor TMHP Pre-Authorizations for orthodontic treatment. We strongly encourage
all providers to schedule monthly periodic visits and to continue treating their orthodontic
patients. MCNA Dental will continue to pay provider’s monthly periodic visits (D8670) and
Debanding/Orthodontic retention (D8680) upon submission of a claim.
While MCNA Dental reserves the right to review any orthodontic case for medical necessity,
effective June 1, 2012, providers are no longer required to re-certify their existing TMHP PreAuthorization through the MCNA Provider Portal, or to send in their orthodontic documentation
to MCNA Dental. Providers are encouraged to treat and complete their existing orthodontic
cases. Any orthodontic documentation providers have already sent to MCNA Dental will be
maintained as part of the member record.
Should MCNA Dental identify an orthodontic case needing review for medically necessity, we
will send a Request for Information Letter to the provider.
Medicaid Orthodontic Update
Transfers
MCNA Dental will reimburse $115.24 for initial evaluation under code D8999. D8999 is a bundled code that can only
be used for transfer patients and includes:
• PANO
• CEPH
• Models or complete set of diagnostic photographs
• Ortho evaluation
• If provider requests to deband to complete treatment, D8680 will be payable.
• If a provider request to deband with the intention to reband, the provider must obtain approval from MCNA Dental
using the Texas Medicaid and CHIP Orthodontic Transfer of Care Form. If the reband is approved, the initial deband
will not be a separately payable procedure and is included in the new approved case rate.
• D8690 will be covered for transfer cases when the provider is not approved to reband the member. D8690 will be
payable @ 19.60 per bracket with a benefit maximum of 5.
For Transfer Cases where the Estimated Treatment Time is 6 months or less, Providers are not required to submit
any additional documentation with their D8670, D8680, and D8690 claims submissions.
For Transfer cases where the Estimated Treatment Time is more than 6 months, Providers are required to submit as
follows with their D8999 claim submission:
CDT Coding and Claims
TDA Question - The TDA acknowledges that reimbursement is not available for D3221 in either
managed care or Fee-For-Service. However, the Association asks MCNA to consider reimbursement for
this code as a debridement may be medically necessary to get the patient out of pain and discomfort
prior to transfer to a specialist. How is MCNA is addressing this issue?
MCNA Dental will continue to follow HHSC’s guidance on D3221 , MCNA is willing to discuss providers
submitting D3221 claims for consideration of payment.
TDA Question - Explain how a dentist bills fluoride as an exception to periodicity. What is the impact on
the client’s Medicaid fluoride benefits?
MCNA Dental understands that there are exceptions to periodicity and should a provider need to
provide a dental prophylaxis and/or fluoride in advance of periodicity, the provider should PreAuthorize the dental prophylaxis and/or fluoride procedure(s). In addition and as part of an Eligibility
Verification, a provider should review a member’s claims history, either in the MCNA Provider Portal or
with the MCNA Provider Hotline, to ensure a dental prophylaxis and/or fluoride has not been
performed within six (6) months, per the AAPD Periodicity Schedule.
Thank you for participating with
MCNA Dental!
Dental Stakeholders Meeting
July 27, 2012
1. Bundling and down coding
 DentaQuest will continue to bundle; however, we are
considering increasing the reimbursement rate for threeand four-surface restorations to bring the fee schedule in
balance. We will have an answer for you soon.
2
2. The portal should include edits/audits features
similar to those available on the Texas Medicaid and
Healthcare Partnership portal so that dentists and
their staff may immediately identify when incorrect or
incomplete information is being uploaded. This will
increase the number of “clean claims.”
 We are reviewing for future enhancements.
3
3. Amendments to the agreements between the dentist
and the dental plans should only be done with the
dentist’s written consent. This helps ensure that the
dentist provider clearly understands changes to the
agreement.
 We have implemented this process in other markets and
providers were not very happy. Under this criterion, if a
provider fails to return the consent, he would be
automatically termed from the network.
Providers could forget to return the form, misplace it or
never receive it. Section 10(b) of the contract outlines the
provider's right to opt out of any amendment or restated
agreement.
4
4. The TDA acknowledges that reimbursement is not
available for D3221 in either managed care or fee-Forservice. However, the association asks DentaQuest to
consider reimbursement for this code as a
debridement. It may be medically necessary to get the
patient out of pain and discomfort prior to transfer to a
specialist. How is DentaQuest addressing this issue?
 We will allow the use of code D3220 from a different
provider than the one who completes the endodontic
procedure. D3221 is currently not a reimbursable code.
5
5. It is extremely concerning to the TDA that DentaQuest
allows dental hygienists to conduct audit/utilization
reviews. As the contracted dentist is legally and
ethically responsible for all dental care delivered to a
Member, only Texas licensed dentists should have the
authority to conduct reviews for DentaQuest.
 A member of our utilization review clinical staff conducts
the preliminary review of the documentation and billed
services for the dates of service subject to the audit.
 All clinical issues identified in the audit are reviewed by
one of DentaQuest’s dental directors. The final clinical
decisions are made by a licensed dentist.
6
7. How many active Medicaid participating dentists,
based upon individual dental license numbers, does
DentaQuest have in their provider network?
 There are 3,748 Medicaid dentists in our network.
8
8. How many active CHIP participating dentists, based
upon individual dental license numbers, does
DentaQuest have in their provider network?
 There are 3,889 CHIP dentists in our network.
9
9. How many individual orthodontists and qualified
general and pediatric dentists does DentaQuest have in
their ortho provider network?
 There are 527 general dentists
 There are 35 pediatric dentists
 There are 276 orthodontists
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Medicaid orthodontic update





11
113 access points accepting transfers
Transfer cases are processing as they are received
489 have been processed as of July 15
24,000 COC cases
New cases
 Received
1804
 Approved
160
 Denied
1644
 Approval rate 8.87%
 Two day turnaround for processing
Please explain how a dentist bills fluoride as an
exception to periodicity. What is the impact on the
client’s Medicaid fluoride benefits?
 In this instance, the provider should submit a narrative
explaining the reason for the exception. It reason must be
documented in the member’s file and on the claim
submission.
 Claims requesting an exception should have the word
“exception” in box 35 of the ADA claim form. If the word is
missing, the claim may deny for exceeding
benefit limitations.
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Thank You
13
39
Stakeholders Meeting
July 27, 2012
Delta Dental
State Government Programs
Texas Medicaid/CHIP
Shawneequa M. Harris, DDS, MPH
Texas Dental Director and Managing Dental
Consultant
Policy for Basic Restorations
Multiple Restorations on the
Same Tooth
Our policy is to combine all
surface restorations on the same
tooth into a multiple-surface
restoration. We will review those
fee codes affected by our current
policy.
DELTA DENTAL WEB
PORTAL
JULY 1ST, 2012
WEB PORTAL INSTRUCTIONS ARE POSTED ON THE INTERNET
Web Claims Submission
In order to submit claims through the provider portal, providers must first
register in the system.
1. Visit: www.deltadentalins.com
2. Click on the “Register Today” link shown below.
3. Follow the instructions.
Web Portal
 There is a link to view/edit claim
submission data and to resubmit.
 If provider data is incorrect, the provider
needs to call Customer Service.
 The link will tell the user why the rejection
occurred.
 These claim reports are typically available
the next business day.
 NOTE: If you are a Fee-For-Service provider, and also
participate in the Texas CHIP and/or Medicaid program,
and are already registered as a Premier/PPO provider,
you do not need to register again.
 Web Claims Submission (WCS) is a secure web
application that dentists and staff can use to data enter
claims for Delta Dental Texas CHIP or Medicaid
members. The user must have access to the Internet,
and basic understanding of desktop computing and web
browsing.
www.deltadentalins.com
Technical or Claims Assistance
Delta Dental Texas CHIP 866-561-5891
Delta Dental Texas Medicaid 877-576-5899
Written Consent for Amendments to
Agreements between Dentist and the
Plans
Amendments to the Provider
Agreement
 Same Provider Agreement, approved by HHSC before
contract, remains in effect
 Section 8.0 of the provider agreement addresses
contract amendments:
“Unless otherwise specifically stated in this Agreement
to the contrary, this Agreement may be amended or
changed only by mutual written consent of the parties.
Notwithstanding the foregoing, Delta Dental may, upon
thirty (30) calendar day written notice to Dentist, amend
this Agreement, or a Dentist Handbook to implement
the provisions of and comply with its obligations under
state and federal law or to meet its administrative
needs.”
Reimbursement for Non- covered
Procedures
Procedure D3221
 Dental vendors do not determine the
services included in the scope of benefits
for Medicaid or CHIP.
 The TMPPM contains a comprehensive
list of all dental Medically Necessary
Covered Dental Services for Medicaid.
Credentialing
Disclosing information regarding
Disciplinary Proceedings with regard to
Delta Dental’s Credentialing Process
CREDENTIALING PROCESS
Documented process for the selection and
retention of contracted providers:
 Complies and adheres with (NCQA)
 Only considers documentation from public domain,
including NPD, TSBDE, etc.
 Follows Texas Department of Insurance guidelines
 No information on dismissed proceedings
 Consider history of malpractice settlements from
NPDB
 Consider administrative penalties issued by TSBDE
as this documentation is from the NPDB
Not discriminating against Members on
the basis of …including their health
status.
Provider Referral
 Each practitioner should use own
judgment as to needs of members based
on professional judgment regarding
treatment rendered for proper oral health
or medical necessity services provider to
members.
 If the member’s health status is beyond
the dentist’s normal practice, he or she
should make the referral.
Information Available on the CHIP
Eligibility Fax Sheet
CHIP Current Benefit Information
and IVR
 Delta IVR designed to meet contractual requirements.
 Verifies member’s eligibility and amounts drawn
against the annual max
Current Benefit Information
CURRENT MAXIMUM: $564.00
MAXIMUM USED:
0.00
 Automated system returns eligibility and benefit
information as of today’s date.
 System will NOT provide correct information for future
dates.
 As eligibility and benefit information may change, the
info given is not a guarantee of eligibility or payment
New Transfer Policy for Orthodontics
Orthodontic Transfer Policy
:
Texas Children’s Medicaid Orthodontic
Services
http://www.deltadentalins.com/group_sites/tchip/providers/
texas-medicaid-orthodontic.pdf
Write “Transfer” in the remarks field or Box 35 of the ADA
Claim Form.
For cases authorized by TMHP & started
prior to 3-1-12 and initiated by another
provider, the following policy applies:
a. Diagnostic procedures may be billed using
procedure code D8999. Payment of $115.24
will include any and all diagnostic services
necessary to evaluate the status of the patient,
including;
 panoramic x-ray,
 cephalometric film,
 orthodontic models,
 photographs,
 orthodontic evaluation.
Orthodontic Transfer Cases
b. The following documentation is required with an
authorization request:
 ADA 2006 (or more recent) claim form with service
codes noted.
 Panoramic radiographs (x-rays).
 Cephalometric x-ray.
 Photographs.
 Treatment plan.
 An explanation of the treatment status.
 Duplicate diagnostic models
 If office uses digital models, submit a printout that
includes at least articulated right and left sagittal
views, cross-section view, upper and lower arch
occlusal views. The images must be in 1:1 ratio.
Orthodontic Transfer Cases
c. The authorization request must identify the number of
periodic orthodontic treatment visits (procedure
D8670) necessary to complete treatment.
d. Medical necessity - based on prevailing community
standards, an evaluation of the member current status,
and whether member is within normal limits in regard
to:
i. Class I Molar and Canine relationship,
ii. Overjet and Overbite,
iii. Root parallelism,
iv. Alignment of dentition.
Orthodontic Transfer Cases
e. If authorization is granted for retreatment
of orthodontic service for any
interceptive or comprehensive treatment
codes (D8050, D8060, D8070, D8080, or
D8090); debanding (D8680) for the
purposes of retreatment will be included
in the fee for the authorized
comprehensive treatment code.
Orthodontic Transfer Cases
f. Procedure D8690 – used for bracket
repair or replacement.
i. If bracket repair or replacement is necessary,
authorization may be granted for up to a max of 5
D8690 .
ii. Additional bracket repairs are considered included in
the fee for the authorized orthodontic services and
not payable by Delta Dental or the member.
iii. Procedure D8690 will not be authorized to a transfer
provider if the provider has received authorization for
interceptive or comprehensive treatment codes
(procedure D8050, D8060, D8070, D8080, or D8090)
Claims for
Supernumerary Teeth
Supernumerary Tooth Numbering System
 Current processing system can only
accept 1-40 and A-T
 A supernumerary tooth submitted using
51-82 is processed as 33-40,
 Our new processing system will allow
payment using the Universal/National
System designation of 51-82 and AS-TS.
Delta Dental
Shawneequa M. Harris, DDS, MPH
Texas Dental Director and
Managing Dental Consultant
1701 Shoal Creek, Suite 240
Highland Village, TX 75077
972-966-6800, Ext. 3305
Q: Jeff Erickson
I would like to ask how we appeal the
decisions of some of the plans: MCNA,
Delta and Dentaquest in regards to
payment. In certain instances payments
are denied or are being underpaid, and
how can we appeal to HHSC.
67
A: Appeals
• Providers need to appeal claims denials through the
dental plans process outlined within the provider
manual.
• If the provider has exhausted the appeal process and
is still not satisfied, the provider may request a peerto-peer review to resolve the claims dispute.
• The determination of the provider resolving the
dispute is binding.
• If the provider has exhausted all avenues with the
dental plan, they may file a complaint at the following
email address:
hpm_complaints@hhsc.state.tx.us
68
Q: Shankee Johnson
Don't understand why MCNA is not
paying for anterior sealants when
Dentaquest and Delta Dental are?
69
A: Anterior Fissure Sealants
• Sealants are intended for fissures and not smooth
surfaces
• Effective August 1, 2012, MCNA Dental will require
Pre-Authorization on anterior sealants
70
Q: Barbara Collard
We have families come in and all their children are
assigned to different insurances. We would really
like to know, as well as our families, how these
insurance companies are assigned. The families tell
us they request certain insurance companies and
when they receive their cards they are assigned to
something different…
Our patients are still having trouble switching
insurance plans. They are being argued with and
told they can't change insurance plans but they will
switch their doctor's office.
71
A: Assignment of Patients to a Dental Plan
• The process prior to 3/1/12
• Clients can choose both their dental plan and the
provider by submitting their application or calling the
enrollment broker/MAXIMUS: (800) 964-2777
• Enrollment hold of new patients to Delta Dental
72
Healthcare Transformation and Quality
Improvement Program 1115 Waiver
• Includes managed care expansion and hospital financing
component, which preserves hospital funding historically available
under upper payment limit (UPL) through a new methodology.
• Delivery System Reform Incentive Payments (DSRIP) available to
Medicaid providers for performing a project intended to transform
care delivery systems by improving:
• Access to health care services,
• Quality and coordination of care provided, or
• Cost-effectiveness of services and health systems.
• Regional Healthcare Partnerships (RHPs)
• Divide the state into 20 regions
• Regional plans are 5-year plans that include a regional needs
assessment and vision for health care in the region
• Regional plans are the basis for defining projects funded from the
DSRIP
Page 73
Healthcare Transformation and Quality
Improvement Program 1115 Waiver
A menu of projects is included in the RHP Planning Protocol and
organized in four categories:
•
Category I: Infrastructure Development - Lays the foundation for the delivery
system through investments in people, places, processes and technology. Pay
for performance.
•
Includes a project to increase, enhance, or expand dental services
•
Category II: Program Innovation & Redesign - Pilots, tests, and replicates
innovative care models. Pay for performance.
•
Category III: Quality Improvements - Disseminates up to four interventions in
which major improvements can be achieved within four years. Pay for reporting,
then performance.
•
Category IV: Population-based Improvements - Requires all regional health
partnerships (RHPs) to report on the same measures. Pay for reporting.
•
Find updated materials and outreach details:
• http://www.hhsc.state.tx.us/1115-waiver.shtml
Submit all questions to:
• TXHealthcareTransformation@hhsc.state.tx.us
•
Page 74
Q: Brian Harris
We have had multiple stories of children who are
being held down or papoose as old as 7 years old
who are traumatized by the experience so much so
that when they come to our office, I can’t even control
their anxiety with a conscious sedation (even though
we try) and as a result we end up in the OR or
referring for IV. Not only does this cost taxpayers
and the state unnecessary expense but creates
traumatic dental experiences for these children who
haven’t been given a choice in any of this.
75
A: Papoose Board
•
•
•
•
•
Armamentarium of Practice/Frequency
Scope of Practice
Standard of Practice
Takeaway from the Round Table
DMO’s may have parent’s sign informed
consent
76
Q: Brian Harris
We have xxxxxxx in Sherman Texas. Existing patients of mine have told me about
them coming door to door with pizza and offering a free exam and cleaning for
the adult if they sign up the rest of the family. Other patient families have been
offered $25 gift cards for coming to their office. In our community, my patients
have been approached at Wal-Mart, the mall, the Laundromat, and even in their
driveways….
Since they have been consistent patients, we have provided comprehensive
care. We may be “watching” some incipiencies and using fluoride
therapy which has been effective in their therapy, but when they go to these
offices they are told they have a cavity. Of course, these clinics offer to fix it the
same day for convenience so they end up leaving with a crown….
These patients have a dental home with my office and have been coming for years,
but they are being enticed by gift cards or pizza, etc. Many of these people are
being taken advantage of or don’t know how to tell the solicitor “NO”.
How can these corporations continue to do this when it is against the TSBDE Rules
and Regs and Dental Practice Act?
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A: Solicitation of Patients
• TAC 353.795(d) (1) states MCOs and
providers shall not conduct any direct contact
marketing except through enrollment events
• This does not infer that providers can not do
mail outs to current clients
• OIG - $10K fine (next slide)
• Per HPO, see the definitions of Marketing
(second slide)
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Consumers Urged to Report Improper
Solicitation or Treatment by Dentists
• The HHSC Office of Inspector General has become aware of
dental clinics directly soliciting Medicaid clients. People hired by
dental clinics have approached HHSC clients in the parking lots
of state benefit offices or neighborhood grocery stores offering a
variety of incentives, including free gift cards, pizzas, and
manicures, in exchange for taking their children to a specific
dentist or clinic.
• Offering inducements to Medicaid clients is a violation of state
and federal law and is subject to a penalty of up to $10,000 per
violation. In addition, some dentists are believed to have
performed unnecessary dental work on children. To report this
or any other suspected act of fraud, waste, or abuse in the
Texas Medicaid program, please visit:
http://oig.hhsc.state.tx.us/OIGPortal/Default.aspx
to Report Fraud click on link or call 1-800-436-6184.
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Definitions of Marketing
•
•
•
•
HHSC Terms and Conditions Contract definition of marketing: any
communication form the MCO (or dental contractor) to a Medicaid or CHIP
Eligible who is not enrolled with the MCO (dental contractor) that can reasonably
be interpreted as intended to influence the Eligible to: (1) enroll with the MCO
(dental contractor) or (2) not to enroll, or to disenroll from, another MCO(dental
contractor).
UMCM Chapter 4.3 definition of marketing: any communication, from an
MCO to a Medicaid or CHIP Client who is not enrolled in the entity, that can
reasonably be interpreted as intended to influence the Client to enroll in that
particular MCO’s Medicaid or CHIP product, or either to no enroll in, or to
disenroll from, another MCO’s Medicaid or CHIP product
CMS definition of marketing (42 CFR 438.104): means communication from
an MCO… to a Medicaid recipient who is not enrolled in that entity, that can
reasonably be interpreted as intended to influence the recipient to enroll in that
particular MCO’s … Medicaid product, or either to not enroll in, or to disenroll
from, another MCO’s…Medicaid product.
Marketing materials is similarly defined (by HHSC and CMS) as: materials
produced in any medium by or on behalf of the MCO (dental contractor) and can
reasonably be interpreted as intending to market to potential members.
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Texas State Board of Dental Examiners
• Lisa Jones
Director of Enforcement
Texas State Board of Dental Examiners
512-463-6400
lisa@tsbde.texas.gov
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State Board of Dental Examiners
Professional Conduct in Business Promotion
• Soliciting or securing patients
• Oral solicitation
• Patient referrals
• New patient gifts
82
Soliciting or Securing Patients
• Criminal offense and professional violation to:
• offer to pay OR agree to accept
• any remuneration
• for soliciting or securing patients
• No recruiters!
• No compensated referrals!
83
TSBDE – Oral Solicitation of Patients
• One-on-one solicitation of patients prohibited.
• DPA Sec. 259.008 bars oral solicitation of
patients “directed to an individual or a group
of less than five individuals.”
• Unprofessional to “intimidate or exert undue
pressure or undue influence over a
prospective patient” DPA 259.005
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Patient Referrals
• Incentivizing new patient referrals prohibited
• Rule 108.60(a)
• May split fees with other dentists or
physicians IF
• prior knowledge of patient
• prior approval of patient
• responsibilities are divided
• This is not a pure referral. It is a splitting of labor
and profit.
• Rule 108.1(7)
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New Patient Gifts
• Current rules allow gifts to new patients
• “$50 gift card to new patients” OK
• BUT consider Medicaid value limits
• Proposed rules prohibit gifts to new patients
• Proposed rules allow gifts to patients of record
• No value limit
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Relevant Rules and Laws
• Board Rules
• Business Promotion: Rules 108.50 to 108.69
• Fee-splitting: Rule 108.1(6)
• Referral Schemes: Rule 108.60
• Texas Law
• Patient Referral and Solicitation: TOC 102.001
• Oral Solicitation: DPA 259.008(2)
• Advertising Rules: DPA 259.005
87
Q: Duane Tinker
Are providers who advertise allowed to
indicate that they accept Medicaid or
"we accept Medicaid"?
88
A: Advertising
• The answer is yes
89
Q: John Walker
I would like a better understanding why Medicaid is not paying
for IV sedation appointment. One company (Delta Dental) is not
paying at all the other two (Dentaquest and MCNA) pay so little
that the anesthesiologist has chosen not to see Medicaid
patients. Also why is there a need for three companies running
the dental aspect because you have three companies with three
different price guides and three different rules on what they will
pay and will not pay. Its more confusing than it ever was before
plus not to mention when you call these companies I may not
get the correct answer to my question or worst yet I will get three
different answers for the same question.
90
A: IV Sedation
• The transition to managed care allows
competition on the part of the MCO’s
• CMS requirement that in Medicaid managed
care the patients must be provided at least 2
options of plans to choose from
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Q: Angela Vega
Continued problems requesting
coverage for implant supported crowns
when an implant exists and is ready for
restoration. What can be done to make
it more well known that this is a
medically necessary covered benefit
when an implant exist?
92
A: Implants
According to the Omnibus Budget Reconciliation Act
(OBRA) of 1989, if the patient presents with an
implant that was placed either through authorization
by TMHP or as a private pay placed when the patient
was not on Medicaid and the only way to
appropriately restore to form and function is with an
implant supported crown then Medicaid should pay
for it. However, if the patient paid for the implant
themselves while on Medicaid, then the patient
should also be held accountable for paying for the
implant supported crown as well.
93
Q: Angela Vega
Repeated denial for SRP's with all MCO's citing no
evidence of significant bone loss. If a patient comes
in with significant calculus and plaque accumulation
that is also beneath the gum line and/or periodontal
disease, are we to only provide a basic prophy and
wait until the child has significant bone loss and/or
tooth loss before addressing the issue
properly? What recommendations can be made on
how to proceed with these cases to address the
patient issue and still expect to receive
compensation?
94
A: Scaling and Root Planing –
These are the CDT Definitons
• 4341 – periodontal scaling and root planing
This procedure involves instrumentation of the crown and root surfaces
of the teeth to remove plaque and calculus from these surfaces. It is
indicated for patients with periodontal disease and is therapeutic, not
prophylactic, in nature. Root planing is the definitive procedure
designed for the removal of cementum and dentin that is rough, and/or
permeated by calculus or contaminated with toxins or microorganisms.
Some soft tissue removal occurs. This procedure may be used as a
definitive treatment in some stages of periodontal disease and/or as a
part of pre-surgical procedures in others.
• 1120 – prophylaxis - child
Removal of plaque, calculus and stains from the tooth structure in the
primary and transitional dentition. It is intended to control local
irritational factors.
95
Q: John Schultz
I would like to know if we will be allowed
to offer payment plans to orthodontic
patients once they are officially denied
by Medicaid due to lack of medical
necessity.
96
A: Ortho Private Pay Arrangements
• Review for Medical Necessity
• New cases with denial for Medical Necessity
• Payment hold – can’t private pay
97
Q: Kerri Tashjian
Patient reps called our office and said that for an
orthodontic transfer case, we should not wait for an
approved authorization from them before seeing the
patient for adjustments. We asked them to provide us
something in writing that said we would get paid by
DentaQuest if we see the patient before we have an
approved authorization but the patient rep could not
provide this information. The patient rep said we
could not deny the patient services. My question to
you is: are we doing something wrong by waiting for
an approved authorization before seeing an ortho
patient for adjustments? Are we in anyway denying
the patient services?
98
A: Ortho Adjustments prior to Authorization
• Review for Medical Necessity on transfer
cases
99
Q: David Ferguson
Recently it has been stated in the stakeholders meeting that Medicaid
providers are not allowed to accept "out of pocket" payments for
orthodontic cases until they have been formally denied by one of the 3
DMO's….
This policy…limits the access to care for Medicaid patients because as
providers it does not make sense to take a Pan, Ceph, intraoral,
extraoral photos, trace a ceph, make a treatment plan, fill out the
criteria form and the ADA form and pay for shipping of all of that
knowing full well that almost every case will be denied and there will be
no reimbursement....
If HHSC is going to require records be submitted and denied for these
patients are they also going to require there be reimbursement for
those records?
100
A: Orthodontic Records
• Coincides with the preceding question.
• HPM requested a policy clarification (see next slide)
related to the ability to obtain a private pay for
orthodontics if the provider knows that the child will
not meet the medical necessity. Dental providers
have the ability to assess and determine whether the
client would meet the orthodontia policy and may
inform the client the option to enter into a private pay
agreement. TMHP bulletin was sent out (private pay
form)
101
A: Orthodontic Records
•
•
•
•
Texas Medicaid will no longer reimburse for any diagnostic workups for
treatment plans that are not approved. Dentists should determine whether the
client’s condition meets orthodontic coverage criteria before performing a
diagnostic workup.
Prior to March 1, 2012, TMHP would reimburse a dental provider for 2 out of
every 10 diagnostic workups for orthodontic treatment plans that were denied.
Effective for dates of service on or after March 1, 2012, TMHP will no longer
reimburse a dental provider for any diagnostic workups for treatment plans that
are not prior authorized. Therefore, dental providers should evaluate each client
thoroughly, before performing a diagnostic workup, to ensure that the client
qualifies and meets all the required medically necessary criteria (13 years of age
and older and have either permanent dentition and a severe handicapping
malocclusion or one of the following special medical conditions: cleft palate,
head-trauma injury involving the oral cavity, or skeletal anomalies involving the
oral cavity) for comprehensive orthodontic services.
The 2012 TMPPM does not state that dental providers are required to submit a
prior authorization request to TMHP in order to get a formal denial for the
service before entering into a private pay agreement with the client.
102
A: Private Pay arrangements for Orthodontia
According to section 1.5.9.1, “Client Acknowledgment Statement” in the 2012
Provider Enrollment Handbook, if the provider determines that the client does
not meet the medically necessity criteria, he/she may enter into a private pay
agreement with the client if the client signs the “Client Acknowledgment
Statement” and requests that the orthodontic services be preformed.
1.5.9.1 Client Acknowledgment Statement
Texas Medicaid only reimburses services that are medically necessary or benefits of special
preventive and screening programs such as family planning and THSteps. Hospital
admissions denied by the Texas Medical Review Program (TMRP) also apply under this
policy. The provider may bill the client only if:
1. A specific service or item is provided at the client’s request.
2. The provider has obtained and kept a written Client Acknowledgment Statement signed by
the client that states: “I understand that, in the opinion of (provider’s name), the services or
items that I have requested to be provided to me on (dates of service) may not be covered
under the Texas Medical Assistance Program as being reasonable and medically necessary
for my care. I understand that HHSC or its health insuring agent determines the medical
necessity of the services or items that I request and receive. I also understand that I am
responsible for payment of the services or items. I request and receive if these services or
items are determined not to be reasonable and medically necessary for my care.”
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Adjournment
•
•
•
•
Q & A with MCO’s in the rear of the room
Time limitation for adjournment
Thank you for your participation
If you have registered for this webinar or you
signed in at the rear of this room you are on
the Distribution List for our next webinar:
October 26, 2012
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