Interactive: Challenges in Texas' Medicaid Dental System

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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