Medicaid Dental Stakeholders M tiMeeting

A il 24 2013April 24, 2013

https://www2.gotomeeting.com/register/499996842

Webinar Broadcast

This presentation is broadcast in Webinar format• This presentation is broadcast in Webinar format with the integrated speakers and microphone of your own computer which happens automaticallyyour own computer which happens automatically

• If you do not have speakers on your computer dial in to the conference call number provideddial in to the conference call number provided

• Webinar attendance requires registration at:

https://www2.gotomeeting.com/register/499996842

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Format for Stakeholders Meetingsg

Stakeholder Meeting anno ncements are posted• Stakeholder Meeting announcements are posted on the HHSC website at:

http:www hhsc state tx us/meetingshttp:www.hhsc.state.tx.us/meetings

Si f t ti di t ib ti th t th• Sign up for automatic distribution the moment the announcements are posted at www govdelivery comwww.govdelivery.com

• Announcements and agendas are posted about 4• Announcements and agendas are posted about 4 weeks prior to Stakeholder Meetings

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Format for Stakeholders Meetingsg

Distrib tion lists for personali ed email broadcast• Distribution lists for personalized email broadcast is based off Webinar attendance, which captures email addresses automaticallyemail addresses automatically

• Stakeholder meetings are held Quarterly:• Stakeholder meetings are held Quarterly:- next occurrence on July 31st, 2013 at 1pm

https://www2 gotomeeting com/register/258986186https://www2.gotomeeting.com/register/258986186- subsequently on October 30th, 2013 at 1pm

htt // 2 t ti / i t /613949010https://www2.gotomeeting.com/register/6139490104

Format for Stakeholders Meetingsg

Q estions posed toda ere s bmitted in• Questions posed today were submitted in advance at:

DentalStakeholdersMeeting@hhsc state tx usDentalStakeholdersMeeting@hhsc.state.tx.us

T d ’ t ti ill b t d th• Today’s presentation will be posted on the HHSC website

• Webinar archives of this meeting posted at:htt // hh t t t / /W bB dhttp://www.hhsc.state.tx.us/news/WebBased_present.asp

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Questions during the Meeting - Votingg g g

The chat f nction of the ebinar ill be sed• The chat function of the webinar will be used to request feedback from stakeholders during this meeting The chat box is located at thethis meeting. The chat box is located at the bottom of the webinar control panel.

• All chats are recorded and captured automatically. We will be using your y g yresponses entered today in the chatbox.

After The Meeting – Question and Answerg

Representati es from the DMO’s are• Representatives from the DMO’s are available at the rear of the room for 30 minutes after this presentationminutes after this presentation.

• They will have internet access but may not be• They will have internet access but may not be able to answer specific claim questions

Introduction of Speakersp

Managed Care Organization (MCO) Dental DirectorsManaged Care Organization (MCO) Dental Directors Dr. Carlos Garcia, MCNA Shannon Turner, MCNA Dr Monica Anderson DentaQuest Dr. Monica Anderson, DentaQuest Brenda Walker, DentaQuestState Agencies (HHSC) Gary Jesse Gary Jesse Emily Zalkovsky Rudy Villareal Colleen Grace Colleen Grace Katy Walter JRGuest SpeakersGuest Speakers

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Regional Stakeholder Meetingsg g

In January 2013 HHSC organized regional dental stakeholderIn January 2013, HHSC organized regional dental stakeholder meetings around the state; each meeting was a town-hall format. Staff facilitated meetings with more than 300 participants in 11 cities including, Amarillo, Corpus Christi, Dallas, El Paso, Fort Worth, Houston, Lubbock, McAllen, San Antonio, Weslaco, and Tyler. All meetings were open to the public. The purpose of these meetings was to allow stakeholders a specific opportunity to share feedback on successes and challenges associated withto share feedback on successes and challenges associated with the transition to dental managed care in March of 2012. At each meeting representatives from HHSC and the two dental plans were present to field clinical and policy questions. Topics discussed i l d d t ti l t h i ti diincluded potential ways to enhance communication regarding policy and process changes, clarification on dental claims, appeals and prior authorization process, main dental home requirements, and credentialing. The remaining 2013 quarterly q , g g q ymeetings are scheduled for April 24, July 31 and October 30. Each meeting will be held in Austin and will include an opportunity for participation via webinar.

Issues and Lessons Learned from Regional Stakeholder MeetingsRegional Stakeholder Meetings

December 2012 – January 2013

Katy Walter

Regional Stakeholder Meetings – Vote 1g g

Were the regional Stakeholder Meetings• Were the regional Stakeholder Meetings conducted throughout Texas in January beneficial to you? How?beneficial to you? How?

• What further input and advice about the structure of future regional meetings wouldstructure of future regional meetings would you like to share? What worked? What didn’t?

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Fluoride Paymentsy

• Procedure code D1208 is a new 2013 HCPCS code• Procedure code D1208 is a new 2013 HCPCS code• It replaces the CDT 2011/2012 codes

o D1203o D1203o D1204

• Statement from DentaQuest and MCNA• Statement from TMHPD1208 code is denied on a submitted claim so that way the rest of the

services billed on that claim can process and pay. Once the rates areservices billed on that claim can process and pay. Once the rates are established (4/1/13) then TMHP will pull all the impacted claims submitted with code D1208 and reprocess them for payment consideration. No further action is necessary from the provider. The

i ff t h ld b i i A il d ill t k f th treprocessing efforts should begin in April and will take a few months to complete

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TMPPM – Online Fee Lookup p

Client Age Non-facility Facility

TOS Desc

Proc

Mo

Mo

Last Pricing

F Th U iConve

i Medic Fee Adju

Adjusted Fee Note

C dConve

i Medi Fee Eff Adju

Note Cod

TOS TOS DescCode

d 1

d 2

gReview

Date

Frm

Thru

Units

Total RVUs

/Base

rsion Facto

r

Medicaid Fee

Fee Effect Date

Adjust

Fee for Report

Date

Codes

Total

RVUs/

Base

rsion Facto

r

Medicaid Fee

Effect

Date

Adjust% Adju

sted Fee for Report

es

1 2 3 1 2 3

Base Units

Base Units

ort Date

THSTEPS DENTAL/OR D1 25 M $0 00 $15 0 9/1/2 $14 $0 00 $15 0 9/1/2 $14 1/1/

W

DENTAL/ORTHODONTIA

D1206 6

251

Months 0.00

$0.0000

$15.00

9/1/2007 -2.00

$14.70 0.00

$0.0000

$15.00

9/1/2007 -2.00

$14.70

1/1/2013

THSTEPS

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W

S SDENTAL/ORTHODONTIA

D1208 6

240

Months 0.00

$0.0000

$14.70

1/1/2013 0.00

$14.70 0.00

$0.0000

$14.70

1/1/2013 0.00

$14.70

1/1/2013

TMPPM – Fees for Fluoride

• Adjust % in the Online Fee Lookup• Adjusted Fee for Fluoride Codes

TOS TOS Desc ProcCode

Mod 1

Mod 2

Client Age Non-facility Facility

Last Pricing Review

DateFrm Thru Units

Total RVUs/

Base Units

Conversion Factor

Medicaid Fee

Fee Effect Date

Adjust%

Adjusted Fee for Report Date

Note Codes

Total RVUs/

Base Units

Conversion Factor

Medicaid Fee

Fee Effect Date

Adjust%

Adjusted Fee for Report Date

Note Codes

1 2 3 1 2 3

WTHSTEPS

DENTAL/ORTHODONTIA D1206 6 251 Months 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 0.00 $0.0000 $15.00 9/1/2007 -2.00 $14.70 1/1/2013

WTHSTEPS

DENTAL/ORTHODONTIA D1208 6 240 Months 0.00 $0.0000 $14.70 1/1/2013 0.00 $14.70 0.00 $0.0000 $14.70 1/1/2013 0.00 $14.70 1/1/2013

• D1203/1204 adjusted at -2.00% • $15.00 minus 2% is $14.70 • D1208 adjusted at 0.00% = $14.70

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Fluoride – Vote 2

• Is the process for submission of Fluoride codes• Is the process for submission of Fluoride codes clear?

• Do any of you require a reach out from TMHP y y qProvider Relations for clarification?

• NOTE: CDT 2014 codes will become effective on January 1 2014!!January 1, 2014!!

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Texas Medicaid EHR Incentive Program:DentistsDentists

Medicaid Health Information Technology (HIT) Team

Year 1: Adopt / Implement / UpgradeYear 2: Meaningful Use)Year 2: Meaningful Use)

EHR Incentive Programg

• 769 dentists in Texas have received incentive• 769 dentists in Texas have received incentive payments for AIU (Adopt / Implement / Upgrade) –which means that they have acquired and/or installed certified EHR technology. That technology could include a web-based system or software. This 769 represents 14% of all eligible professionals who haverepresents 14% of all eligible professionals who have received an AIU payment.

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EHR Incentive Programg

• 9 dentists in Texas have received incentive payments• 9 dentists in Texas have received incentive payments for Stage 1 Meaningful Use (MU) – which means they have met the program and reporting requirements for the first year of Meaningful Use (meaningful use measures, clinical quality measures, etc.). This represents 1% of all eligible professionals who haverepresents 1% of all eligible professionals who have received an MU payment.

• Note: Dentrix Enterprise submitted their application in March 2013 to the testing body for Meaningful Use certification.

• Quote: “Our application is being reviewed and we will soon have a testing and certification date scheduled” -Max Sessions, Product Management, Dentrix Enterprise

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The Program in a NutshellThe Program in a Nutshell

• Incentives of up to $63,750 are available for the adoption p $ , pand meaningful use of certified electronic health record (EHR) technology:

AIU (Ad t I l t U d ) i th fi t f ti i ti• 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 EPsFinal 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.

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Patient Volume ThresholdPatient Volume Threshold

Payment Year by EP TypeMedicaid Patient

Volume *

Incentive Amount

Max. cumulative incentive

over 6 years

Year 1 for most EPs30% or higher $21,250

$63,750 Years 2-6 for most EPs30% or higher $8 500

• Pediatric dentists are eligible for the lower patient volume threshold of 20%.

30% or higher $8,500

Year 1 for pediatricians and pediatric dentists 20% to 30% $14,167

$42 500Years 2 6 for pediatricians and pediatric• Pediatric dentists attesting to 20-30% Medicaid patient volume will be required to upload documentation that they are either board certified in pediatric dentistry, or they completed a pediatric dentistry residency.

$42,500 Years 2-6 for pediatricians and pediatric dentists 20% to 30% $5,667

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* If the EP practices predominantly in an FQHC or RHC, patient volume threshold is 30% Needy Individual volume

(Medicaid, CHIP, uncompensated care, sliding scale).

EPs: AIU and Stage 1 Requirements

• First year of program participation: Upload documentation that

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 Core6 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) Immunizations2) Reportable Labs2) Reportable Labs3) Syndromic Surveillance

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How to Register and Attest

1. Register at CMS: https://ehrincentives.cms.gov.

How to Register and Attest

2. 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.

3. Gather required information and documentation:• EHR certification number.• Group or individual attestation choice.p• Patient volume information (numerator and denominator).• AIU documentation.

4. Log into the portal and attest. Go to www.tmhp.com and log in.4. 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

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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 Incentive Program”

Additional Resources

• Learn about the Texas Medicaid EHR Incentive Program through a self-

Additional Resources

g gguided 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)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• 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”.

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• Submit questions by sending an email to HealthIT@tmhp.com or calling 1-800-925-9126, option 4.

New TDA Website – Vote 3Have you accessed it yet?Have you accessed it yet?

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Organized Dentistry at work for youg y y

Ne TDA ebsite!!New TDA website!!

T D t l A i ti (td )• Texas Dental Association (tda.org)http://www.tda.org/displaycommon.cfm?an=1&subarticlenbr=2325

• The Texas MeetingSan Antonio Convention CenterMay 2 5 2013May 2-5, 2013(www.texasmeeting.com)

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Organized Dentistry at work for youg y y

Q estions to DentaQ est and MCNA areQuestions to DentaQuest and MCNA are regularly posed by Organized Dentistry:

• Texas Dental Association (www.tda.org)( f t d ’ t ti )(source for today’s presentations)

• Texas Academy of Pediatric Dentistry (www tapd org)(www.tapd.org)

• Texas Academy of General Dentistry (www tagd org)(www.tagd.org)

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Texas Dental Association

The TDA will conduct its next quarterly meeting withThe TDA will conduct its next quarterly meeting with Health and Human Services Commission and the dental plans on April 25 2013dental plans on April 25, 2013.

The meeting will take place at the TDA ExtensiongBuilding.

Th ti b lThe times are below: DentaQuest 9:00 AM to 10:35 AMMCNA 10:40 AM to 12:15 PM

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MCNA 10:40 AM to 12:15 PM

Texas Dental Association

•Main Dentist Assignment and Changes•Referrals to Other Dentist Providers for Specialty Care•Replacement Sealants by a New Dentist Provider•Network Adequacy and Specialist Availabilityq y p y•TDA Open Records Request April 2013•Processing Emergency Claims by Other Than Main Dentist

Discuss Topics DentaQuest•Referrals from a facility (Not Main Dentist) to Multiple Specialistsat the Same Time and Claims Payment•Dental Work in a Hospital Setting - payment to Hospital and Not Performing Dentist Provider

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p g•Differences in Reimbursement for Preventive Resins (D1352) between Medicaid and CHIP

Texas Dental Association

• Main Dentist Assignment and Changes• Main Dentist Assignment and Changes• Referrals to Other Dentist Providers for Specialty Care• Replacement Sealants by a New Dentist ProviderReplacement Sealants by a New Dentist Provider• Network Adequacy and Specialist Availability• TDA Open Records Request April 2013• Processing Emergency Claims by Other Than Main Dentist

Discuss Topics MCNA• Continued D7140 and D7111 definition• PRR when does MCNA pay for this covered benefit?

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• PRR…when does MCNA pay for this covered benefit?• Periapical radiographs with Tooth#

D1206 reporting with OEFV – Vote 4p g

Early Childhood Caries - the most common chronic disease f M di id hildof Medicaid children.

I would recommend that we consider unbundling the current medicalCPT code for oral evaluation and fluoride varnish for children up toCPT code for oral evaluation and fluoride varnish for children up to 36 months.

Mary Dale Peterson MD MSHCAMary Dale Peterson, MD, MSHCAPresident, Driscoll Health Plan

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D1206 reporting with FDH – Vote 5p g

Texas Medicaid/CHIP data is being used for reliability and feasibility g y ytesting for the Starter Set of Pediatric Oral Health measures, under the supervision of the Dental Quality Alliance (DQA) at the ADA

Our External Quality Review Organization (EQRO) has reported our data for FDH visits, recorded by bundled code D0145, as not including fluoride varnish application

D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver

D1206 topical application of fluoride varnish

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Q: Henry Chuy

I am writing with regard to the requirement for authorizations for periodontal g g q ptreatment. We see individuals with special needs who cannot cooperate in office for any type of examination or xrays due to a physical or intellectual disability.Current rules state that we must have authorization before we may provideCurrent rules state that we must have authorization before we may provide treatment. For this population, it would require one general anesthetic to do the exam, one general anesthetic to debride and probe, one general anesthetic to provide the scaling and root planning, one general anesthetic to provide the prophy and fluoride.p op y a d uo deThis increases the risk for a patient because the induction and emergence from general anesthesia are the most risky parts of the procedure. Performing these treatments at the same visit under general anesthesia makes the most sense for this population.p pIn addition, patients are limited to one session under general anesthesia with the current regulations. So these patients would not receive care.

I have attached photos of a patient we saw yesterday who will likely loose all of p p y y yhis teeth.

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A: Special Needs Anesthesiap

Anesthesia is c rrentl a benefit t ice per earAnesthesia is currently a benefit twice per year per patient.

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SC S k h ld iHHSC Stakeholders MeetingApril 24, 2013

Important MCNA UpdatesImportant MCNA Updates

• MCNA is pleased to announce that Appeals may now be submitted via the Provider Portal. Please be advised that faxing is not recommended forbe advised that faxing is not recommended for appeals as images sent are not of diagnostic quality.

• Effective April 15, 2013, the reimbursement rate for D7111 h b i d t $30 00D7111 has been increased to $30.00.

Important MCNA UpdatesImportant MCNA Updates

• In order to communicate more frequently to our network of Providers MCNA has also introduced “Dental Details ” aProviders, MCNA has also introduced Dental Details, a monthly newsletter outlining items of interest to the Provider community.

• Also, a new Provider Manual will be coming soon. This single document will replace the Covered Services Manual and the current Provider Manualcurrent Provider Manual.

NarrativesNarratives

A detailed narrative should include the following:• Specifics of tooth #, surface, and/or location involved

• A description of any medication dispensed, how it was given and

how much was given

• Details including any symptoms the patient was having such as pain• Details including any symptoms the patient was having such as pain,

swelling, and/or infection.

• Any compromising medical or physical condition of the patient y p g p y p

• When applicable please include duration of procedure performed

Questions and AnswersQuestions and Answers

Thank you!Thank you!

D t Q t D t lDentaQuest – Dental Stakeholders Meeting April 24, 2013

Important DentaQuest UpdatesImportant DentaQuest Updates DentaQuest is pleased to announce that Appeals and Peer to Peer requests

may now be submitted electronically via the Provider Portal. Please visit www dentaquesttexas com for additional training informationwww.dentaquesttexas.com for additional training information.

DentaQuest changed the layout of the Texas Roundup to enhance the provider experience. The bi-weekly publication has been a part of provider education since the start of the program and is posted on the portal and www.dentaquesttexas.com.

DentaQuest has implemented the PURL process which allows providers toDentaQuest has implemented the PURL process which allows providers to receive alerts when critical information is posted to the portal.

An updated Office Reference Manual (ORM) was posted January 29, 2013. Going forward providers will be notified via the portal and PURL process of anyGoing forward, providers will be notified via the portal and PURL process of any changes made to the manual.

Best Practices Training…DentaQuest has added “Best Practices Training” based on Provider feedback during the statewide Stakeholder meetings. Best Practices Training includes the following:Training includes the following:

Understanding the Office Reference Manual Most common denial reasons Most common denial reasons Medical necessity Clinical criteria Narratives Narratives X-rays/photos Appeals process

Please visit www.dentaquesttexas.com for training dates and copies of the PowerPoint. In addition, office training can be scheduled by contacting your Provider Relations Representative.your Provider Relations Representative.

Reporting Marketing / SolicitingReporting Marketing / Soliciting Violations… Any incidents of Marketing / Soliciting violations may be reported to

your Regional Provider Relations Representative. A list of Representatives can be found at www.dentaquesttexas.com under P id I f ti T i iProvider Information, Training.

DentaQuest investigates all reports which includes, but is not limited to the following:the following:

Research the report to see if we can validate first hand Contact the provider and provide additional education as needed Contact the provider and provide additional education as needed Cease and desist letter to the provider for subsequent violations

Questions and AnswersQuestions and Answers

Thank You!

Complaintsp

• Providers can appeal claims denials through the• Providers can 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 peer-to-peer review to resolve the claims disputeto-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:email address: HPM_Complaints@hhsc.state.tx.us

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Provider Relations

• TMHP (tmhp com)• TMHP (tmhp.com)

• DentaQuest (dentaquesttexas com)DentaQuest (dentaquesttexas.com)(800) 896-2374

• MCNA (mcnatx.net)Internal RepsExternal Reps

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Solicitation of Patients

TAC 353 795(d) (1) states MCOs and• TAC 353.795(d) (1) states MCOs and providers shall not conduct any direct contact marketing except through enrollment eventsmarketing except through enrollment events

• This does not infer that providers can not do mail outs to current clientsmail outs to current clients

• OIG - $10K fine (next slide)• Per HPO see the definitions of MarketingPer HPO, see the definitions of Marketing

(second slide)

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Consumers Urged to Report Improper Solicitation or Treatment by DentistsSolicitation or Treatment by Dentists

• The HHSC Office of Inspector General has become aware of• 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 aof 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 Marketingg

• HHSC Terms and Conditions Contract definition of marketing: anyHHSC 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(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 thatreasonably 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 MCO t M di id i i t h i t ll d i th t tit th tan 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. 48

Texas State Board of Dental ExaminersProfessional Conduct in Business PromotionProfessional Conduct in Business Promotion

Soliciting or sec ring patients• Soliciting or securing patients

O l li it ti• Oral solicitation

• Patient referrals

• New patient gifts

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Soliciting or Securing PatientsSoliciting or Securing Patients

Criminal offense and professional iolation to• Criminal offense and professional violation to:• offer to pay OR agree to accept• any remuneration• any remuneration• for soliciting or securing patients

• No recruiters!

• No compensated referrals!

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TSBDE – Oral Solicitation of Patients

One on one solicitation of patients prohibited• One-on-one solicitation of patients prohibited.

DPA S 259 008 b l li it ti f• DPA Sec. 259.008 bars oral solicitation of patients “directed to an individual or a group of less than five individuals ”of less than five individuals.

• Unprofessional to “intimidate or exert undue• Unprofessional to intimidate or exert undue pressure or undue influence over a prospective patient” DPA 259.005prospective patient DPA 259.005

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Relevant Rules and Laws

Board R les• Board Rules• Business Promotion: Rules 108.50 to 108.69• Fee splitting: Rule 108 1(6)• Fee-splitting: Rule 108.1(6)• Referral Schemes: Rule 108.60

• Texas LawTexas Law• Patient Referral and Solicitation: TOC 102.001• Oral Solicitation: DPA 259.008(2)( )• Advertising Rules: DPA 259.005

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TMPPM reformat of fields

CDT Age Tooth Surf Freq Limit PA Docu Clinicmentation

al

D0100toD9999

0To999

A-T,1-32

M,O,D,L,B/F

Yes or No

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TMHP reformat of fields

Standardi e the format of TMPPM dental• Standardize the format of TMPPM dental policies with medical policies

• More importance that the clinical efficacy of• More importance that the clinical efficacy of the therapy

• Comprehensive listing of the variables• Comprehensive listing of the variables associated with each code could be listed

• This will become a resource document andThis will become a resource document and will communicate far more effectively what is covered, when it is covered and what documentation is needed for submission

54

TMPPM reformat of fields – Vote 7

CDT Age Tooth Surf Freq Limit PA Docu Clinicmentation

al

D0100toD9999

0To999

A-T,1-32

M,O,D,L,B/F

Yes or No

55

Orthodontic Policy – Vote 8y

Redefinition of Medical Necessity for OrthoRedefinition of Medical Necessity for Ortho

• handicapping malocclusion so severe it• handicapping malocclusion so severe it requires surgery to correct

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AdjournmentAdjournment

THANK YOU FOR BEING A TEXAS• THANK YOU FOR BEING A TEXAS MEDICAID AND CHIP PROVIDER !!!

• Thank you for your participation via webinarIf h i t d f thi bi• 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:the Distribution List for our next webinar:

July 31 2013

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July 31, 2013https://www2.gotomeeting.com/register/2589861

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