17 Apr ADA Medicaid Resolutions: They Make the Provider and Patient Experiences Better
By Dr. Rhonda Switzer-Nadasdi, immediate-past volunteer on the ADA’s Council for Advocacy for Access and Prevention (CAAP)
I love it when I see our new ADA vision statement “empowering dental professionals to achieve optimal health for all” being embraced. One way the ADA accomplishes this is by encouraging dentists to participate in Medicaid. As an incentive, the ADA created a Medicaid Provider Reference Guide and Advocacy Toolkit, which serves to educate providers and encourages greater collaboration with state Medicaid agencies to continually improve their programs. Common sense Medicaid reform must improve enrollee access, quality of care, reduce administrative burdens on dentists, and be cost effective. If such reforms are successful, it will be a win/win for the patient, state Medicaid agency, taxpayer, managed care company, and dental benefits manager, as well as participating dentists. Often, this entails increasing provider reimbursement rates, but that is not always feasible based on political and fiscal climates within individual states. Incentivizing dentists to become Medicaid providers is not the only approach. Removing disincentives can be equally as valuable.
To this end, the ADA’s Council on Advocacy for Access and Prevention’s (CAAP) Medicaid Provider Advisory Committee (MPAC) continues to seek ways to reduce the administrative burdens and perceived risks associated with provider participation in Medicaid and CHIP. This article will explore four ADA resolutions on Medicaid that do just this. It will also provide practical examples of how and why these actions could be a game-changer in states that implement these resolutions.
The 2015 ADA House of Delegates passed two actions that laid a solid foundation for state Medicaid agencies to support strong dental Medicaid programs (Trans: 2015.275):
- The American Dental Association encourages all state dental associations to work with their state Medicaid agency in hiring a Chief Medicaid Dental Officer, who is a member of organized dentistry.
- The American Dental Association encourages all state dental associations to actively participate in the establishment or continuation of an existing Medicaid dental advisory committee that is recognized by the state Medicaid agency as the professional body to provide recommendations on Medicaid dental issues.
My home state of Tennessee is one of about a dozen Medicaid managed care states that have carved out their dental program. This means that the state contracts directly with a dental benefits manager (DBM) for administering dental benefits versus contracting with a medical managed care company (MCC) that in turn subcontracts for dental services. Benefits of a dental carve out include greater DBM accountability because of a dedicated dental budget and detailed dental contract provisions, such as scope of services, enrollee access, dental network adequacy, utilization management, utilization review, quality of care and oral disease prevention, program integrity, claims processing, adjudication and payment, enrollee outreach and education. There are also liquidated damages assessed to hold the DBM’s feet to the fire in instances where specific requirements have not been met.
Tennessee has had a Medicaid chief dental officer (CDO), Dr. Jim Gillcrist, for almost 17 years. Jim is both the CDO and the TennCare dental director, who has direct oversight of all Medicaid and CHIP dental contracts. He understands dentistry, has treated patients, has a specialty degree in dental public health, and is an ADA member dentist. I have worked closely with Jim for many years and know him to be a dedicated public servant who understands how to improve the oral health of underserved populations through thoughtful collaboration with dentists and other health professionals.
In addition, our state Medicaid agency felt it was important to hire an associate dental director, Dr. Crystal Manners, who is also an ADA member dentist. Tennessee is twice blessed to have these professionals at the helm to work closely with the DBM. A chief dental officer helps establish the overall vision for the Medicaid dental program, which is focused on moving from dental treatment to oral health prevention and value-based care. It is critical to have dedicated dental leadership at the Medicaid agency to hold the DBM accountable for contractual obligations. The chief dental officer can have heightened responsibilities, especially in those states with multiple medical and dental MCCs to ensure proper dental oversight and coordination across multiple stakeholders.
Tennessee was one of the first states to establish a Medicaid Dental Advisory Committee, which serves as a forum for participating dental providers to bring forth concerns through their representatives to the committee as a whole. It allows for brainstorming, problem solving, the sharing of ideas, enhanced communication, state updates, and professional input for improving enrollee utilization and quality of care. Although the committee recommendations are not binding on the state, the vast majority of its recommendations over the past 17 years have been adopted, which improved quality of care and cost efficiency.
Committee member seats include representatives from multiple dental associations (e.g. Tennessee Dental Association and Pan Tenn-Dental Association), each of the major dental specialties, a member of the Tennessee Dental Hygienist Association, dentists from all three grand visions of the state, Colleges of Dentistry (University of Tennessee and Meharry), the Tennessee Primary Care Association (representing federally qualified health centers), the state Department of Health, faith-based charitable dental care and the DBM. This advisory committee provides critical input and recommendations to increase the use of proven oral disease prevention modalities, medical necessity criteria and periodicity scheduling. Some states include a consumer representative. In Tennessee, this advisory committee is weighted more towards representing dental professionals, rather than member advocacy or politically oriented actions.
The 2017 and 2018 ADA House of Delegates passed subsequent actions that encouraged fairness and equity within audits conducted via the state Medicaid agency itself or through a contracted entity (Res. 33H-2017 and 69H-2018)
- The American Dental Association encourages all state dental associations to work with their respective state Medicaid agency to ensure that Medicaid dental audits be conducted by dentists who have similar educational backgrounds and credentials as the dentists being audited, as well as being licensed within the state in which the audit is being conducted.
- The American Dental Association encourages all state dental associations to work with their respective state Medicaid agency to create a dental peer review committee, made up of licensed current Medicaid providers who provide expert consultation on issues brought to them by the state Medicaid agency and/or third party payers.
In Tennessee, the Medicaid dental contract between the state and DBM requires, as part of their utilization review process, that the DBM have a dental provider peer review committee made up of licensed dentists in good standing with the Tennessee Board of Dentistry, who are well-versed in TennCare’s medical necessity rules and guidelines prior to reviewing cases. I serve on the DBM dental peer review committee along with other Tennessee general dentists, pediatric dentists, oral surgeons, orthodontists, and endodontists, all of whom are Medicaid providers themselves.
Our DBM dental peer review committee reviews complaints arising from patients, dental staff or other providers; however, the vast majority of reviews concern dentists whose treatment practices deviate significantly from other in-network dentists performing similar procedures based on dental specialty and where chart audits reveal suspected fraud or abuse. Close professional scrutiny by the dental peer review committee in such instances is a serious undertaking. Everything is conducted with the utmost professionalism. The information is strictly confidential with the committee not informed of the names of the dentists or the area of the state where they practice.
The committee guides the DBM as to quality of care concerns, lack of compliance with the office reference manual policies, and/or medical necessity criteria. The committee reviews the findings presented at each meeting and delivers its consensus findings in writing. Such recommendations may necessitate review of additional enrollee case files from certain dentist offices, site visits of certain offices, provider and staff education, recoupment of provider payments and/or any combination of these actions.
In particularly egregious cases, the committee has even recommended the removal of a provider from the DBM’s network. Usually provider education is enough to modify a provider’s errant behavior and re-establish them as a beneficial member of the dental provider network. Findings and recommendations of the dental peer review committee are shared with TennCare’s Program Integrity Unit.
Though these actions have helped many states improve the oral health of Medicaid-eligible individuals, there remains an ongoing challenge of recruiting enough dentists to provide the care that is needed and retaining those currently participating. It would help for participating dentists to know that when questions about their practice arise, their unique circumstances will be reviewed and evaluated in a fair and equitable manner by their peers. A peer review committee made up of state licensed general dentists, pediatric dentists and other specialists would answer that need.
I have served on both my state dental association’s peer review committee and our State Medicaid program peer review committee. They are distinctly different entities with each having an entirely different rationale and set of standards. The state dental association’s peer review committee mediates cases between patients and dentists, which tries to satisfy a dissatisfied customer. The DBM peer review committee on the other hand is designed to ensure that participating dentists are following the Medicaid rules, policies, and medical necessity criteria as laid out in the Medicaid reference manual, and to ensure that enrollees receive appropriate dental care. Dentists voluntarily agree to follow these when they sign their provider agreements to become Medicaid providers.
Improving Medicaid should involve more than just dollar infusion. It necessitates collaboration among the key stakeholders, namely the state Medicaid agency, health plan(s) and state dental association(s). If dentists and other health professionals are truly committed to being leaders and advocates for oral health, then they must make a concerted effort to work closely with these stakeholders to implement practical measures that all state Medicaid dental programs could benefit from, such as those presented in these four ADA resolutions.