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

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

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,

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!

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

Documents

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

MEDICAID DENTAL PROGRAM

MEDICAID ENROLLEES NEED CLINICAL TRIAL ACCESS

LIBERTY’S FLORIDA MEDICAID DENTAL PROGRAM

Statewide Medicaid Managed Care Dental Program OverviewThe Dental Component of the Statewide Medicaid Managed Care Program • Beginning in December 2018, Medicaid recipients will

MEDICAID DENTAL PROGRAM Policy Review. What is Medicaid? Wyoming Medicaid is a joint federal and state government program that pays for medical and dental.

ADA.org: Dental Medicaid - 2012 - American Dental Association

Medicaid and Medicare Enrollees Need Dental, Vision, and ...

Ohio Medicaid Group VIII Assessment...Medicaid Group VIII Assessment examined how Medicaid expansion has affected new enrollees with respect to access and utilization of health care,

Web viewPitkin County tops the list with an increase of 177 percent, growing from 447 Medicaid enrollees in 2013 to 1,240 enrollees in 2014. Indeed,

Coordination of Medicaid Dental and Medicaid …...The Coordination of Medicaid Dental and Medicaid Services Report is submitted in compliance with the 2018-19 General Appropriations

Chapter 1: Mandatory and Optional Enrollees and Services ...Mandatory and Optional Enrollees and Services in Medicaid Key Points • Medicaid is a partnership between the federal government

2018 Ohio Medicaid Released Enrollees Study...Difficulties navigating the Medicaid enrollment process can be a major obstacle for enrollees to receive needed care, i and the MPRE program

The Medicaid Analytic Extract 2010 Chartbook · system derived from the Medicaid Statistical Infor-mation System (MSIS), which contains extensive information about Medicaid enrollees

Hearing from Medicare-Medicaid Enrollees: Findings from 2011 Focus Groups Medicare-Medicaid Coordination Office Centers for Medicare & Medicaid Services.

Care Management for Medicaid Enrollees Through Community .../media/Files/Publications/Fund Report... · CaRE maNaGEmENT FOR mEDICaID ENROLLEES THROUGH COmmUNITy HEaLTH TEamS Mary

Vermont Medicaid Dental Supplementdvha.vermont.gov/.../Dental/2dentalsupplement.pdf2019-03-08 Dental Supplement 5 . Section 1 Introduction The Vermont Medicaid Dental Supplement contains

Appendix A Federal Medicaid Waivers · Medicaid Model: Approximately 90 percent of Medicaid enrollees are in managed care. The remaining 10 percent includes Native Americans and emergency

Medicaid and SCHIP Data for Harris County Enrollees and Providers September 2007

Statewide Medicaid Managed Care Dental Program …...The Dental Component of the Statewide Medicaid Managed Care Program • Beginning in December 2018, Medicaid recipients will have

Medicaid Adult Core Measures Set...Medicaid Adult Core Measures Background In an effort to improve the quality of services provided to Medicaid enrollees and to increase transparency