Monica F. Anderson, DDS - National Dental Association · Medicaid Dental Beneﬁts Medicaid covers...

MonicaF.Anderson,DDSDentalBenefitsConsultant,AADCNationalDentalAssociation104thConventionDallas,TexasJuly23,2017

DiscussionTopics

q HistoryofMedicaid&CHIPinDentistryq BarrierstoCareq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends

Disclaimer:Thecontentofthislectureandopinionsexpressedarethoseoftheauthoranddonotrepresenttheofficialopinionsoftheconferencehost,theworkshopsponsor,oranycompanywithwhichIamaffiliated.

2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.

LikePullingteeth…


HealthCareSafetyNet

“Healthcareprovidersthatdelivercareinavarietyofsettingstoadiversegroupofpeople.Theseprovidersincludepublichospitals,communityhealthcenters,localhealthdepartments,freeclinics…thatdelivercaretolow-income,vulnerablepatients.”-WakeForestUniversity

CreditJennyDowning/FLICKR

q HistoryofMedicaid&CHIPinDentistryq BarrierstoAccessq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends


SocialSecurityActof1935

10RegionalOffices

CMS

Medicare Medicaid CHIP HIX

1in3AmericansisinaCMSProgram


https://en.wikipedia.org/wiki/Social_Security_Acthttps://en.wikipedia.org/wiki/Medicaid

EssenBalHealthBenefits� Emergencyservices� Hospitalization� Pregnancy,maternity,newborncare� Mentalhealthandsubstanceusedisorder� PrescriptionDrugs�  Labservices� Pediatricservices,includingoralcare(butadultdentalcareisnotcovered)


MedicaidDentalBenefitsMedicaidcoversdentalservicesforallchildenrollees(age18andyounger)aspartofacomprehensivesetofbenefits,referredtoastheEarlyandPeriodicScreening,DiagnosticandTreatment(EPSDT)benefitFederallymandateddentalbenefitsforchildrenmustminimallyincludeservicesfor:ü  Reliefofpainandinfectionsü  Restorationofteethü Maintenanceofdentalhealthhttps://www.medicaid.gov/medicaid/benefits/dental/index.html


EPSDTandMedicalNecessityEarlyandPeriodicScreening,DiagnosticandTreatment(EPSDT)isamandatoryFederalchildhealthprogramforMedicaidrecipients,emphasizing�  Screening�  Earlydiagnosis�  Necessarytreatment

UndertheMedicaidprogram,statesdeterminewhatbenefitsarecoveredandtheydefine“medicalnecessity”


Children’sHealthInsuranceProgram(CHIP)InDenBstry

� CHIPisanoptionalMedicaidprogramdesignedforthechildrenofworkingfamilieswhoareuninsuredbutdonotqualifyforMedicaid(age20oryounger)

� CHIPcoverageisbasedonfamilysizeandincome� Coverageincludestreatmenttopreventdisease,restorefunctionandtreatemergencyconditionsperfederalpolicyguidelines




AccesstoCare�  2000,theSurgeonGeneral’sreportemphasizedtoothdecayisthemostchronicailmentforchildren

�  2007DeamonteDriverdiesfromoralhealthcomplications

�  2017proposedchangeslikelywillnotexpandoralhealthcarebenefits

� Only32%ofU.S.dentistsinprivatepracticeacceptMedicaidpatients

� MillionsofchildrencoveredbyMedicaiddonotreceivedentalcareorroutineexams


WhyBother?�  “Toomuchredtape,brokenappointmentsandunappreciativepatients.”(Alaskadentist)�  “Medicaidratesaresolow,theydon'tevencoveroverhead.”(Floridadentist)�  “Thegovernmentshouldraisethereimbursementssotheyareatleastinlinewithinsurancecompanylevels.”(Nebraskadentist)�  “Withallthedentistsbeingprosecutedandsomethrowninjaillatelyforwhatappeartobehonestcodingmiscodingmistakes….It'sjusttoorisky.”(Texasdentist) http://thewealthydentist.com/surveyresults/084-dental-medicaid-patients.htm

Reason#1DentalDiseaseisTooPrevalent

AndItIsPreventable


Reason#2MedicaidandCHIPcanwork

foryourpracBce


SeTngReimbursementRates� TheStatesdecidewhatiscoveredandthereimbursement/encounterrates

� Commercialinsurancerates,datafromhealthplans,stakeholderinput,andotherfactorsareusedbyanactuarialfirmtodeveloprates

� Alwayssubmityourregularfees,nottheallowedfees


Administrators

� Moststatescontractwithvendors/MCO’s/TPA’stoadministertheirprograms

�  StatespayMCO’sacapitationrateper-member-per-month(PMPM)tooperationalizethesepublicfundedbenefitplans(managedcare)


ThirdPartyAdministrators(TPA)Statespaythirdparties(businesses)toadministerthedentalbenefits.TPA’sprovidecustomerservice,claimsprocessing,clinicalmanagement,andmaintaintheprovidernetworkTwoprimarymodelsforfundingStateprograms:1.  AdministrativeServicesOnly(ASO)-TPAispaida

fee(PMPM)toadministertheprogram.Claimsarepaidusing“dedicatedfunds”fromthestate.

2.  FullyInsured(RISK)-TheStatepaysafixedamountfortheadministrativeservicesandpaymentofclaims

Ref:Smithwick,C.,DentalBenefitsAGuidetoManagedPlans,3rded.,2010

ReimbursementRates

April2015–“RepublicanGov.MikePenceannouncesIndiana’sMedicaidexpansionplaninJanuary.PartofthatplancallsforraisingreimbursementratestotrytopersuadedoctorstoacceptMedicaidpatients.Fourteenotherstatesaredoingthesame.”(AP)

Credit©AP


FeeSchedules�  Acomprehensivelistofmaximumallowablefeesonafeeforservicebasis

�  Feesmayvarybyprovidertype,specialty,placeofservice,clienttype,orotherfactors

�  Refertotheadministrator’scurrentMedicaidProviderProcessingPolicyManualforcoveredservices.


FreetransportaBon=DecreasedNoShows&

Overbooking


LanguageBarriersMedicaidprovidesinterpretersforfreeandfreerelayserviceformemberswhoarehearingorspeechchallenged



KeyConcepts�  LeastExpensiveAlternativeTreatment(LEAT)akaLeastExpensiveProfessionallyAcceptableAlternativeTreatment(LEPAAT):theleastcostlyacceptabletreatmenttorestorefunction

� ManagedCare:Provisionofbenefitsbymanagingutilizationandcostusingcontractedproviders,reducedprices,pretreatmentreview,utilizationfunctions,auditsandplandesign.


ClaimsAdjudicaBonProcess� Claims,priorauthorizations(PAR)receivedandadjudicatedelectronically.

� Manyaresystematicallyapproved,reviewnotrequired

� ClaimsReviewers(asst’s,hygienists,nurses)determinewhatcanbeapprovedforpaymentwithoutDentalConsultantReviewusingalgorithmsbasedonpolicy

� ClaimsReviewerssendhighcostprocedures,miscellaneouscodes,medicalcodes,complexproceduresandpossibledenialsforclinicalreview.

DentalBenefits:AGuidetoManagedPlans,3rded.Smithwick2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.

RoleofTheDentalConsultant/Reviewer

Ø  Plansdonot/cannotofferfinancialincentivestoconsultantstodenyappropriate,necessarytreatment

Ø Qualified,licenseddentistsmakedecisionstoclinicallydenyorapprovecoverageusingevidencebasedguidelines,regulations,processingpoliciesandprofessionaljudgment

Ø  Peertopeercalls,StateFairHearings,ReviewGrievancesØ Monitorindustrychanges,bestpractices,&latestresearch

Ø DetectpotentialFraud,Waste,andAbuse(FWA)


ClinicalGuidelinesAAPDGuidelinesonmaxillaryfrenectomy–midlinediastemawiderthan2mm,preventorthodonticrelapse,traumaticpullonthegingiva,difficultynursing…butalsoincludestheword“optionsvary”

OpensourceImagesFrenectomytoday.com2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.

StandardsofCareLegalDefinition:Whatareasonableandprudentdentistwoulddounderthesameorsimilarcircumstances’


AutomaBon=Faster,Be^er,StrongerClaimsProcessing

�  InvestinIT(EHR)tosavetimeandmoney�  Submitclaimselectronically�  Submitattachments(periocharting,xrays)usingFastAttachbyNEAorasimilarsystem

�  Feweradmindenials,fasterreimbursement,lesspaper,bettersecurity


DigitalRadiography

Ref:http://ffden-2.phys.uaf.edu/104_2012_web_projects/Elizabeth_Goldsmith/Digital_Radiography_files/shapeimage_3.jpg

APictureIsWorthAThousand…

Ref:Dental%20Implant%20Scann%20Proposal

CodeonDentalProceduresandNomenclature(CDT)

� CDTprocedurecodesarecreatedandownedbytheADA

� ©2017ADA.AllRightsReserved� CDT2017isthemostcurrent� OnlyHIPAA-recognizedcodesetfordentistry� Accuratecodesincreasereimbursement

q HistoryofMedicaid&CHIPinDentistryq BarrierstoCareq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends


AGOODNARRATIVE:

� Toothspecificanddescribesthesymptomsthatarebeingexhibitedbythemember� Ifthememberisorhasbeenonantibiotics,includenameanddosage� Ifthememberisorhasbeenonpainkillersforanextendedperiodoftime,includethisinformation� Ifthemember’sageorbehaviorcouldbeadeterminingfactor,elaborate� Ifthereisanysymptompresentthatisnotidentifiablebyviewingthex-ray,thisshouldbeincluded

2017CopyrightM

onicaFAnderson,

DDS.C

onfidentialandProprietary.

HIPPAA-FederalLegislaBon

HealthInsurancePortabilityandAccountabilityActof1996(HIPAA)includedtheseimportantprovisions-q RequiredtheU.S.DepartmentofHealthtocreatestandardsforelectronichealthcaretransaction

q Establishedstandardsforthesecurityofhealthdata


CommonHIPAAViolaBons

� Notadheringtothepatient’sauthexpirationdate�  Failuretopromptlyreleasecopiesofmedicalrecords�  Improperdisposingofmedicalrecords� NosignatureonHIPAAforms� Releasinginfotoanunauthorizedparty� Releasingunauthorizedhealthinformation� Releasingwrongpatient’sinfo�  Formsareinvalidwithouta“righttorevoke”clause� UnprotectedstorageofPHI


BeforeyouCallthePlan,WhyWasTheProcedureDenied?�  Isitaclinicaldenialoranadministrativedenial?� Didyousubmittheproperdocumentation?� Checkthefrequency,agelimitations� Eligibility?� Timeliness?� Non-diagnosticradiographs,preandposttxpa’smayberequired


ResubmitorAppeal?� Thereisadifference-doyouneedtosubmitrequireddocumentationordoyouneedclinicalreview?

� AlwayssendALLtherequireddocumentationwitheachsubmission.Includetheclaim,txnotes,diagnostictests,intraoralphotosandpre/postradiographseachtime.

� ReferenceanypreviousauthorizationsorcommunicationinBox35.Donotonlysend“requestedmaterial”i.e.postoppaoranarrative.Itmaynotgetattachedtotheprevioussubmission.


PeertoPeerCalls

�  Licensed,experienceddoctors

� Beprofessional�  Listencarefullyandaskquestions

�  Speaktothedentalconsultantpersonally� Reviewwhatwassubmittedbeforeyoucall


AppealsandFairHearings� Theplanshavespecificproceduresformembersandproviderstoappealclinicaldecisions

� Refertotheprovidermanualorportalfortheprocess.Itisdifferentforprovidersandmembers

� Usethecorrectform.DonotsendanastygramtotheDentalConsultantwhodeniedtheclaim

�  SubmityourappealorgrievancewithintheTPA’sdeadlinewhichbeginsfromthedateyoureceivetheadversedecision




TheBusinessofHealthCare


Fraud:Actionsthat“knowinglyandwillingly”schemetodefraudforthepurposeofobtainingmoneyorproperty.

Intentionallysubmittingfalseinformation.


UnBundling

Codeforwhatyoudo, dowhatyoucodedfor.


Coding�  ForcodeD2150,twocontiguoussurfaces,#3MOshouldbeonasingleline

�  If#3presentswithanMOandaseparateDO,thesecodesshouldbelistedontwolinesofthesameclaimform.

�  Insurancewilllikelyallowa3-surfacerestorationiftheyareformedonthesamedayorwithinashorttimeperiod.

http://www.dentaleconomics.comvolume-93,issue-3


Waste:

Overutilization,unnecessarycosts,misusebutnotcriminallynegligent


Abuse:

Paymentwithnolegalentitlement.Actionsthatareimproper,inappropriate,outsideacceptablestandardsofprofessionalconductormedicallyunnecessary.




Importanttrends

� QualityImprovementPrograms/Processes�  ImprovingOralHealthCareDeliveryModels� CommunityPartnerships� PerformanceImprovementProjects(PIP)forStatesandHealthPlans

� RiskAssessments


“Improvedquality.Lowercost.”Dr.PatrickConway,CMSDeputyAdministratorforQualityandInnovation

Bettercare.Lowercost.PatientCentered.Betterhealth.


PayForQuality(P4Q)� Appliestostates,plans,andpractices� AdministratorsmustmeetState/Federallymandatedmetrics,turnaroundtimes,qualitymeasures

� Evidencebased,datadrivencoordinatedcareisthenewmodel

� Movingawayfromacutecaretolongtermoutcomes,patientcentriccare


DentalQualityAlliance(DQA)ThemissionoftheDQAistoadvanceperformancemeasurementasameanstoimproveoralhealth,patientcareandsafety.Objectives�  Toidentifyanddevelopevidence-basedoralhealthcareperformancemeasuresandmeasurementresources.

�  Toadvancetheeffectivenessandscientificbasisofclinicalperformancemeasurementandimprovement.

�  Tofosterandsupportprofessionalaccountability,transparency,andvalueinoralhealthcare.


NewWorkforceModelsforCareDelivery

� ExpandedFunctionDentalHygienists

� DentalTherapists

� Remote/Teledentistry

� CommunityBasedClinics


DentalTherapistsByusingdental

therapists,statesareprovidingabasichealthservicefor

vulnerablecommunities…

Minnesotawasthefirststateto

authorizethedentaltherapyprofession

eightyearsago.-JohnGrant,PewCharitableTrust


CommunityPartnerships


IntegratedHealth�  Employeebenefitssystemthatconnectsmedicalandnonmedicalbenefitsandrecord(dental,pharmacy,vision…)

�  Coordinatedapproachtoimprovingoverallhealth�  CaseManagement�  Bundleddentalandmedicalinsuranceplans

Accordingtothe2017AnthemIntegratedHealthCareReport,60%ofmorethan200surveyedemployersareeitherimplementingoractivelyconsideringimplementingintegratedhealthcarebenefitplans.


� www.drmOeanderson.com� NeedaSpeaker?Convention,LocalChapter,StudyClub,AssociationMeetings…

� Emailme:info@drmOeanderson� Twitter~@drmOeanderson

Questions?Comments?


ThankYou!Enjoytheconference!


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Monica F. Anderson, DDS - National Dental Association · Medicaid Dental Beneﬁts Medicaid covers...

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