The state's dental program for the most impoverished and medically needy children is facing major challenges. As the Tribune previously reported, the state is currently addressing the problems, but dentists say the short-term outlook for the Medicaid dental program is dim. This interactive examines some of the data behind the challenges facing lawmakers, dental providers and the children they serve.
Fewer than half of the 3.5 million children eligible for dental services through Medicaid received preventive dental treatments — such as teeth cleanings, fluoride treatments or sealants to prevent cavities — in fiscal year 2011, according to records submitted by the state to the federal government. More than a third, 1.38 million eligible children, didn’t receive any dental treatment. This isn't a new obstacle, and utilization of dental services has improved since 2007, when the Legislature appropriated an additional $1.8 billion to children's dental services through Medicaid in response to a lawsuit that alleged the state had failed to provide adequate care for children on Medicaid. The number of children receiving dental services has gone up since then, but so has the number of fraud allegations.
Much of the current controversy surrounding the Medicaid dental program is the volume and costs of medically unnecessary dental procedures approved by the state. It's unknown exactly how many of the dental procedures approved by the state in 2011 were not medically necessary, but some dentists say the state’s previous fee-for-service payment model encouraged overutilization of services. More corporate-owned dental clinics moved to Texas after the infusion of funding in 2007, and because doctors were paid more for each filling, root canal or pulpotomy (like a root canal on a baby tooth), as reports from other parts of the nation have documented, some companies have given dentists financial incentives to perform more procedures on Medicaid children. This graph highlights the number of claims and total costs for some of the procedures that could have been overutilized.
In October, Byron Harris of WFAA-TV in Dallas reported that the state was spending millions of dollars to put cosmetic braces on Medicaid children. As the Tribune reported, the state’s attempts to crack down on dental clinics abusing Medicaid services have left many children without orthodontic treatment. A new rule established by federal health reform allows the state to hold payments to dental providers while they conduct fraud investigations. Many of the corporate-owned clinics have shut down as a result, and orthodontists who originally received state approval to put braces on Medicaid children’s teeth are no longer treating those patients. When the state transitioned to Medicaid managed care in March, stricter rules were put in place to qualify “medically necessary” orthodontic care, and many of the claims to continue treatment that were submitted by the children’s new orthodontists were denied. Some children were forced to wait months to have their braces tightened, fixed or examined, while the state figured out how to handle their cases. At a hearing in July, the managed care organizations said they are working with the state and providers to ensure those children finish their orthodontic treatments.
In total, the state approved nearly 260,000 new claims to put braces on Medicaid children — at a cost of $134.8 million — in fiscal years 2010 and 2011. Here's a look at the geographical breakdown of where those claims came from and which clinics filed the most claims.
50 Top Paid Dental Clinics for Medicaid Braces* in FY 2010 - 2011 | ||||
---|---|---|---|---|
Provider Name | Amount Paid for Braces | Claims for Braces | Address | City |
NAVARRO ORTHODONTIX | $2,019,560 | 5,410 | 2505 CORNER STONE BLVD | EDINBURG |
NAVARRO ORTHODONTIX | $1,984,430 | 5,229 | 1024 E LOS EBANOS BLVD | BROWNSVILLE |
NATIONAL ORTHODONTIX MGMT | $1,342,060 | 1,890 | 1620 SPID STE 230B | CORPUS CHRISTI |
NATIONAL ORTHODONTIX MGMT | $1,198,230 | 2,135 | 7878 GATEWAY BLVD E STE 300 | EL PASO |
NATIONAL ORTHODONTIX MGMT | $1,159,200 | 1,715 | 7878 GATEWAY BLVD E STE 201 | EL PASO |
NATIONAL ORTHODONTIX MGMT | $889,614 | 1,332 | 7500 N MESA SUITE 304 | EL PASO |
M AND M ORTHODONTICS | $823,803 | 2,168 | 3543 ROOSEVELT AVE | SAN ANTONIO |
NAVARRO ORTHODONTIX | $821,766 | 2,154 | 5901 BELLAIRE BLVD STE 105 | HOUSTON |
M AND M ORTHODONTICS | $785,387 | 2,039 | 9530 POTRANCO RD | SAN ANTONIO |
NAVARRO ORTHODONTIX | $783,135 | 2,025 | 5322 E US HIGHWAY 83 STE 2C | RIO GRANDE CITY |
ANTOINE DENTAL CENTER | $781,716 | 1,077 | 6206 ANTOINE DR | HOUSTON |
NAVARRO ORTHODONTIX | $770,878 | 1,032 | 2511 CORNERSTONE BLVD | EDINBURG |
GOODWIN, MICHAEL D | $756,743 | 2,491 | 3629 WOLFLIN AVE | AMARILLO |
M AND M ORTHODONTICS | $750,776 | 1,956 | 3545 ROOSEVELT AVE | SAN ANTONIO |
MEJIA-MAIDL, MARTHA | $701,048 | 2,363 | 1800 MCRAE | EL PASO |
CAYCEDO, CLAUDIO H | $700,151 | 1,073 | 2430 QUAKER AVE | LUBBOCK |
HARLINGEN FAMILY DENTISTRY | $680,006 | 1,846 | 1214 DIXIELAND RD STE 4PC | HARLINGEN |
SIMMONS, TROY W | $674,853 | 1,782 | 402 NORTH FORT | PALESTINE |
CHU, STEPHEN | $659,859 | 1,095 | 201 S GREENVILLE AVE STE 108 | RICHARDSON |
MEJIA-MAIDL, MARTHA | $641,155 | 2,112 | 9130 VISCOUNT BLVD | EL PASO |
ORTHOGENESIS INTERNATIONAL CENTRE SOUTH | $586,324 | 779 | 4151 BOB BULLOCK LOOP STE 212 | LAREDO |
ALL SMILES DENTAL PROFESSIONALS | $574,324 | 743 | 4200 SOUTH FWY STE 1550 | FORT WORTH |
GARCIA, GEORGE | $560,772 | 1,340 | 6801 MCPHERSON RD STE 104 | LAREDO |
SUPER SMILES DENTAL | $557,302 | 1,459 | 2110 N GALLOWAY AVE STE 120 | MESQUITE |
M AND M ORTHODONTICS | $553,628 | 1,454 | 6735 FM 78 BLDG 1 STE 106 | SAN ANTONIO |
HERRSCHER, RICHARD F | $546,601 | 710 | 1001 S PALESTINE ST. | ATHENS |
RGV SMILES BY ROCKY L SALINAS DDS PA | $536,644 | 1,411 | 805 N CAGE BLVD SUITE D | PHARR |
SUN ORTHODONTIX | $525,766 | 876 | 108 PROFESSIONAL PARK DR | VICTORIA |
ALL SMILES DENTAL PROFESSIONALS | $524,380 | 699 | 817 W JEFFERSON ST | DALLAS |
A PERFECT SMILE ORTHODONTICS | $502,951 | 2,135 | 1400 E EXPRESSWAY 83 STE 155 | MCALLEN |
SMILE STRAIGHT ORTHODONTICS PLLC | $497,410 | 683 | 1502 N ZARAGOZA RD STE B | EL PASO |
ALL SMILES DENTAL PROFESSIONALS | $476,599 | 618 | 1604 NEW YORK AVE | ARLINGTON |
ALLIED ORTHODONTIC SERVICES | $466,383 | 1,000 | 16103 W. LITTLE YORK SUITE 0 | HOUSTON |
HEART OF TEXAS COMMUNITY | $465,337 | 1,079 | 1600 PROVIDENCE DR | WACO |
GOATES, LARRY J | $460,782 | 638 | 3602 MATLOCK ROAD STE 202 | ARLINGTON |
ALL SMILES DENTAL PROFESSIONALS | $457,906 | 593 | 2628 MATLOCK ROAD | ARLINGTON |
LONE STAR ORTHODONTICS | $455,400 | 1,253 | 7517 CAMERON RD STE 106 | AUSTIN |
PROFESSIONAL ORTHODONTIC ASSOCIATES | $444,462 | 584 | 701 N HAMPTON RD | DESOTO |
M AND M ORTHODONTICS | $439,607 | 1,171 | 4422 DE ZAVALA RD | SAN ANTONIO |
EVANS, GERALD S | $434,470 | 987 | 2000 ESTERS ROAD | IRVING |
CASSON, WAYNE A | $423,022 | 583 | 1110 AVE E | DEL RIO |
CORINA DIAZ BAJSEL | $416,182 | 1,105 | 5616 LAWNDALE BLVD A204 | HOUSTON |
HERNANDEZ, HERIBERTO A | $399,579 | 915 | 4400 NORTH FWY STE F350 | HOUSTON |
CORINA DIAZ BAJSEL | $395,412 | 879 | 5616 LAWNDALE ST STE A201 | HOUSTON |
NAVARRO ORTHODONTIX | $390,064 | 1,028 | 508 W MCDERMOTT DR SUITE 100 | ALLEN |
EVANS, GERALD S | $386,037 | 895 | 3434 W ILLINOIS AVE STE 204 | DALLAS |
REAL SMILES | $381,900 | 497 | 3330 MANSFIELD HWY STE B | FORT WORTH |
DRS BIRTH AND STEWART ORTHODONTICS | $380,225 | 493 | 3060 SYCAMORE SCHOOL ROAD | FORT WORTH |
DR SHELIA BIRTH ORTHO KELLER | $373,286 | 490 | 5407 BASSWOOD BLVD #107 | FORT WORTH |
VAN DYKE DENTAL ASSOCIATES | $370,175 | 520 | 7112 ED BLUESTEIN BLVD STE 100 | AUSTIN |
*The amount paid is how much the dental provider was given for diagnostic tests and to initially put braces on the child. It does not include payments for additional visits and claims, such as to tighten wires or fix brackets.
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