DENTAL INSURANCE WORKING GROUP AND MEDICAID WORKING GROUP CONTINUE ASSISTING MEMBER DENTISTS WITH PROBLEM CLAIMS AND OTHER MATTERS – PART 1
No matter how diligent and efficient a dental office’s billing staff or dental insurance administrators are, there is always a possibility that their dental office may run into problems and/or misunderstandings with dental insurance companies or other third-party payers. These can range from minor annoyances to larger, more costly and frustrating situations. It is at these times when the Ohio Dental Association may be of assistance.
Institutional credibility of the ODA with dental insurers and Medicaid, coupled with individual personal relationships between the ODA volunteer dentists and ODA staff with individual policymakers and decisionmakers within many Ohio based dental insurance companies, Ohio Department of Medicaid (ODM), General Assembly and the governor’s office can be brought to bear on different issues to assist individual practitioners and/or the profession as a whole.
“The ODA is in a unique position to help member dentists resolve third-party payer payment and credentialing problems. Most individual dentists simply can’t call, text or email decisionmakers at Medicaid or various dental insurance companies to resolve all of their problems on their own,” said Dr. Maryann Jacko, chair of ODA Council on Dental Care Programs and Dental Practice. “ODA volunteer member dentists and ODA staff have developed relationships over the years with many of the payers we deal with on a regular basis and are able to use those relationships to assist individual member dentists address problems they’re unable to resolve on their own.”
Medicaid
Ohio’s Medicaid program provides publicly funded health care coverage to about 3 million low-income Ohioans (or about 26% of the state’s population), including children, pregnant women, older adults, people with disabilities and other adults. It is jointly funded by a roughly 65-35 split of federal to state tax dollars for most Medicaid expenditures in Ohio. The sheer size of Ohio’s Medicaid program can significantly impact the state’s health care system, including the dental benefits marketplace.
The ODA Medicaid Working Group was created by the Council on Access to Care and Public Service in 2006 to both provide recommendations to the ODA’s leadership on issues related to Medicaid and to assist ODA member dentists in addressing Medicaid issues and problems that they are unable to resolve on their own. The collective efforts of the working group, council, Executive Committee, grassroots dentists and ODA staff have resulted in a number of positive outcomes for individual ODA member dentists in recent years.
Episodes of Care
ODM created the Episodes of Care Program as part of its efforts to improve quality of care in the Medicaid system through value-based payments for the treatment of a wide variety of medical services and two dental services (extractions and opioid prescriptions). The program unfortunately created unintended consequences which resulted in many Ohio dentists being sent judgments that they had to repay the state and/or Medicaid HMOs significant sums of money, ranging from a few thousand dollars to over $64,000.
The ODA responded by working with the member dentists who contacted the ODA, communicating behind the scenes with ODM staff and filing a formal complaint with ODM. The ODA’s intervention and ODM’s willingness to address the situation resulted in very favorable outcomes for every member dentist who contacted the ODA with none having to repay any money to the state or any HMO.
Multiple procedure reduction pricing
When the ODA brought to ODM’s attention problems the ODA identified with how Multiple Procedure Reduction Pricing (MPPR) was being applied to Medicaid fee-for-service dental claims last year, ODM responded immediately. The department identified that Centers for Medicare and Medicaid Services (CMS) resource-based relative value scale (RBRVS) data that Medicare uses for payment of physician services was being incorrectly applied to dental claims and took immediate steps to fix the problem and restore the correct reimbursement amounts to all affected dentists. (MPPR is used by government and many commercial insurers in cases where a health care provider performs multiple procedures during a single patient encounter to typically pay “full price” for only the highest-valued procedure while reducing reimbursement for the other procedures that were provided during the same patient encounter.)
Operating room reimbursement
The ODA and the Ohio Academy of Pediatric Dentistry contacted ODM concerning coding practices and reimbursement levels for dental treatment that must be provided in hospital or ambulatory surgical center operating room settings for patients whose extensive dental needs require the use of anesthesia, the majority of whom are covered by Ohio Medicaid. ODM’s very timely response in favorably addressing both the coding and reimbursement issues should help increase access to care for many children who need dental services under general anesthesia. The ODA’s action helped prevent dentists’ fees from being halved.
Medicaid fees nearly double
The highlight of the ODA’s Medicaid advocacy efforts in recent years came with the implementation of an average 93% increase in Medicaid fees that took effect at the beginning of last year. It was a culmination of years of hard work by grassroots ODA member dentists, the ODA lobbying team, ODM, Gov. Mike DeWine, the Ohio General Assembly and other oral health care advocates. It was the first significant Medicaid dental fee increase in Ohio in nearly a quarter of a century and one of the largest across the entire country. The Medicaid Working Group, along with the ODA staff and professional lobbying team, worked with ODM officials to ensure all the funding that was approved in the state budget was directed towards patient care in the form of increased fees and not plan administration.
Many dentists have contacted the ODA expressing their interest in incorporating more patients covered by Ohio Medicaid into their practices. Other callers have indicated the new Medicaid fees are comparable to or better than many of the preferred provider organizations (PPOs) they participate in. Some have even reported that they have been able to leverage the Medicaid fee increase into better reimbursement from some of the PPOs they contract with.
The ODA is continuing its Medicaid advocacy efforts as House Bill 96, the biennial state budget bill, makes its way through the legislative process to ensure the Ohio Medicaid budget contains the funding necessary to continue the dental program at its current covered services and fee levels.
5% rural county dental service bonus
In early March, a member dentist contacted the ODA when his office identified that he was not receiving the 5% “bonus” for providing care in one of Ohio’s designated rural counties from Anthem Blue Cross Blue Shield and its dental administrator, LIBERTY Dental Plan. The ODA contacted the dental directors at Anthem and LIBERTY and both directors immediately worked to resolve the matter for the ODA member dentist and then took steps to address it for other affected dentists, thereby ensuring they are paying the correct rates including the 5% bonus where appropriate.
Medicaid Working Group working with Medicaid HMOs to address orthodontic case adjudications and other matters
Early this year, the ODA met with high ranking ODM representatives regarding their concerns with how Ohio’s Medicaid HMOs were handling orthodontic prior authorization requests. They believed too many prior authorizations were being inappropriately denied and asked for the ODA’s assistance in addressing the matter. Since then, the dental directors for all seven of Ohio’s Medicaid HMOs have worked collaboratively among each other and with the dentists who volunteer on the ODA’s Medicaid Working Group to develop an orthodontic evaluation form for use in all orthodontic prior authorization requests. Once it is rolled out, this scientifically based form should provide a new level of transparency, reliability and accountability for all involved in the prior authorization process.
In addition to addressing orthodontic case adjudications, the working group is in the process of meeting with Ohio’s seven Medicaid HMOs to address issues of concern and ways to improve the administration of the Medicaid program. The working group has already met with high level officials at four HMOs.
“The ODA as an institution and ODA volunteer dentists and ODA staff as individuals have developed a high level of credibility, trust and familiarity with key ODM officials and Medicaid HMO representatives,” said Dr. Jennifer Kale, chair of the ODA Medicaid Working Group. “We’ve been able to leverage our relationships with state and HMO officials to assist individual member dentists work through Medicaid related problems they may have encountered, including getting dentists into networks in a timelier manner than they could on their own.”
Next month’s Dental Insurance Corner will address the ODA’s role in assisting individual member dentists in dealing with privately funded dental insurance plans.
