Medicaid Dental System an Ongoing Challenge

While Texas works to fix a system that allowed dental clinics to charge the state millions of dollars in questionable Medicaid bills, dental providers say impoverished Texas children do not have adequate access to care and that the state’s rocky transition to Medicaid managed care is compounding the problem. 

Concerns over the system will be addressed Friday, when the state’s Health and Human Services Commission holds a "dental stakeholders" meeting in Austin. Dr. John Roberts, the dental director for CHIP and Medicaid at HHSC, said the dental directors of managed care health plans, members of state government and other state officials will address 14 questions previously submitted by dental providers across the state. One topic on the agenda: "Discussion on orthodontic continuation of care for abandoned patients."

Shannon Ash of Lewisville says her three teenagers haven’t been able to get their braces checked by an orthodontist for two months and are using wax to hold off the pain from wires cutting into their cheeks. After the dental clinic that had gotten state approval to put braces on her children shut down, the children’s new orthodontist told Ash that the Medicaid managed care dental plan assigned to her children by the state didn’t think her children’s braces were medically necessary. Therefore, it wouldn’t reimburse the orthodontist for treatments.

“I don’t have money to take care of the issue, or else I would have had it done myself,” Ash said. “If I had known this [would happen], I would have just let my kids’ teeth be crooked.”

After news broke last fall that Texas was paying millions to dental clinics for fraudulent or unnecessary Medicaid activities, such as putting cosmetic braces on low-income children, the state cracked down. The Health and Human Services Department's Office of Inspector General has put 23 orthodontic clinics on payment holds since October while it investigates fraud allegations. And managed care organizations that began administering Medicaid dental plans in March are placing stricter requirements on dental providers to prevent fraud.

“We don’t have a way of credibly quantifying how many patients have had their treatment affected or delayed” because of payment holds on dental clinics put in place while the OIG investigates fraud allegations, said Geoffrey Wool, a spokesman for HHSC. “We are advising those who feel uncomfortable about going to their dentist to call their dental plan and select another dentist who can continue the treatment.”

Dentists and orthodontists agree that the fraud and abuse of children at some corporate dental clinics is a serious problem that the state is addressing. But they say the state’s methods are making it difficult for providers to treat Medicaid patients. They say providers are often forced to refile reimbursement claims and wait months for payments as managed care organizations determine whether the claims meet their stricter determination of “medically necessary” dental care.

“Right now this is a mess,” said Dr. Gene Kouri, a Fort Worth pediatric dentist who has served Medicaid patients since 1952. “A lot of the young dentists don’t have the funds to pay their bills, their salary or their rent because [the state is] holding their money by making them refile and refile.”

Many corporate-owned dental clinics were able to move in after the 2007 Legislature allotted an additional $1.8 billion to children’s dental services in response to a lawsuit that alleged the state had failed to provide adequate care for children on Medicaid.

Richard Black, an El Paso orthodontist and legislative chairman of the Texas Dental Association, said the infusion of funds, coupled with the state’s previous fee-for-service reimbursement model “and limited state oversight made Texas an attractive practice environment for many large corporate dental clinics.”

Although not all of the dental clinics backed by financial firms are committing fraud or abuse, Black said, interference in dentists’ decisions by financial firms “can manifest in a conflict of interest between patient care and corporate profitability.”

As reports from other parts of the country have documented, dentists at some corporate clinics have been given financial incentives to perform unnecessary, and arguably inhumane, dental procedures on children.

“All these people are concerned about is making money; they’re not worried about the children,” said Kouri, who added that he often has to correct damage done to children’s teeth by general dentists at such clinics. 

At a legislative hearing in April, leaders of the Texas State Board of Dental Examiners, which regulates dental licenses in Texas, told lawmakers that the agency can only regulate individual dentists’ licenses and, therefore, did not have the tools to regulate corporate dental practices. The board said its only recourse after receiving an allegation of Medicaid fraud at a corporate dental clinic is to notify the Office of Inspector General and other law enforcement agencies.

In the long run, Black said, oversight by managed care organizations, “which is going to be far, far, far more stricter than what was going on with the state,” will create better utilization of taxpayer funds. “In the short run, and I believe that’s in the next 24 months, there is this huge problem to deal with,” he said.

“We’ve got thousands of patients who are running around with braces on who have not been seen by an orthodontist since March,” said John Gober, a pediatric dentist who owns three clinics in the Dallas-Fort Worth area. Gober said that he and other dentists feel like their hands are tied when it comes to helping these children because the state won’t reimburse them for removing the braces and they could face liability for interrupting the child’s orthodontic treatment. “I’m scared I’m going to get a letter from some guy demanding $10,000 or he’s going to sue me or drag me through the mud.”

State Sen. Jane Nelson, R-Flower Mound, said this problem would be a top priority in the 2013 legislative session. “Using patients to game the system — and then abandoning those patients when you get caught — is shameful abuse,” she said in a statement. “It robs us of resources, makes it harder to meet our needs, and creates hardships for patients through no fault of their own.”

But Gober and other dentists believe the state needs to take responsibility for these children, particularly those with untended braces, immediately.

“They’re going to have to step up, at least get these kids that have wires poking them — they can’t find anybody to treat them,” said Gober, emphasizing that it’s not the children’s fault that orthodontists were submitting claims for medically unnecessary care. “The state came back and approved all of them. In my mind, those children should be taken care of and should be paid for.”

For a child on Medicaid to get braces in the first place, the state must have approved dental records submitted by the child’s orthodontist. The scoring sheets submitted by orthodontists are subjective, and it’s the state’s responsibility to evaluate whether orthodontic treatment is medically necessary. For example, if a child has a cleft palate or severely deformed teeth, orthodontics may be medically necessary to ensure the child receives adequate nutrition.

The state contracts the Texas Medicaid and Healthcare Partnership (TMHP) to evaluate and administer Medicaid claims. HHSC officials told a state Senate committee in March that they are currently addressing “performance issues” with TMHP and that the OIG is conducting an audit of the prior orthodontia authorization process at TMHP.

TMHP “did not provide enough qualified people to evaluate the cases. They approved a lot of them without really evaluating them,” said Robert Anderton, a former dentist and lawyer representing some of the dental clinics that are having Medicaid funds withheld as a result of the fraud investigations.

Anderton said that not all of the accused dental clinics are guilty of fraud, and by withholding funds the state is forcing these clinics out of business, thus exacerbating the problem of access to dental care for some patients. One client, he said, was placed on a payment hold for two weeks before the OIG re-evaluated the case and determined that it did not have enough evidence to continue withholding payments. “All of these orthodontists are being treated as if they were guilty, so there’s a severe lack of due process in their cases,” he said.