contract dental services · • we are responsible for all permanent charting, prior authorizations...

Contract Dental Services

Reba Rice, Chief Executive Officer Jess Fairbanks, QI Manager

Contact Information

• Reba Rice, CEO – [email protected] – 715-372-5001 x 1212

• Jess Fairbanks, Quality Improvement Manager – [email protected] – 715-372-5001 x 1339

mailto:[email protected]

mailto:[email protected]

Background • Our Ashland Dental Clinic opened Spring 2009. • Targeted Emphasis

– Currently two full-time dentists. – Kid-Focus, + pregnant women and adult emergencies. – We take only Medicaid and low income uninsured.

(very limited insurance—just for continued care.) – Need/Demand for adult services since day one.

• Contract Dental Program – Signed contracts with 3 providers March of 2011. – Saw first patient in April 2011. – Program put on hold as of January 2012.

Why did we contract? • CHC mandate to respond to community needs.

– With only 1-2 dentists, we can’t do it all! – Only 3 private dentists in our service area (4

counties) were accepting new Medicaid patients. – Our only adults=emergencies and pregnant women. – All other adult patients referred to other CHCs, all at

least an hour away. • Our local state senator requested that we work

with private dentists that had been talking with him about challenges with seeing Medicaid patients due to low reimbursement.

Initial Barriers to Program • HRSA

– Control! – “Four Walls” issues – Change in Scope process

• Medicaid – Payment equity – Limiting access

• Lack of trust between private dentists and CHCs

Barrier Busting! • HRSA

– Anything “in scope” is within 4 walls – Adding Dental Services in Column II

• Medicaid – CHIPRA memo from CMS:

• “a State may not prevent a Federally-Qualified Health Center (FQHC) from entering into contractual relationships with private practice dental providers in the provision of FQHC services”

• Straight talk with ‘coalition of the willing’

Program Development • Choosing providers

– All taking new Medicaid patients – Excited about partnership – Supportive of/interested in additional CHC services

• Building relationships

– Trust – Transparency – Communication – Shared commitment to leading change!

Program Goals • Increase access to dental services.

– Adults across our service area – Children far from our clinic

• Strengthen small businesses in our community. • Improve WDA/FQHC relationships. • Provide a sustainable way to increase access for

our patients and increase our own encounters (needed to break even financially).

• Create a replicable model.

• Patients of the Program are OUR patients. • We are responsible for all permanent charting,

prior authorizations with Medicaid necessary for treatment, and referral services for patients.

• We provide Resource Coordination for patients – assisting patients with Medicaid eligibility and applications, food stamps, heating assistance, transportation, etc.

• Contracted dentists are responsible for submitting all claims to us each month.

Contract Obligations

Contract Obligations • Contracted dentists serve patients getting other

services (Medical, Mental Health) at CHC. • The contract includes a list of covered and non-

covered services – Non-covered services require prior approval – Very similar to MA covered/non-covered services.

• We are responsible for verifying eligibility for MA patient and slide status for self-pay patients upon registration, and contracted dentists are responsible for checking eligibility the day of the appointment.

• Contracted dentists carry their own malpractice/ liability insurance.

• Contracted dentists responsible for maintaining WI Medicaid Provider status.

• Contracted dentist responsible for participating in the Lakes Quality Assurance Program, including chart audits and reporting.

Contract Obligations

Dental Services Coordinator (DSC) • Key to success! The program requires TLC. • Handles patient registration and eligibility determination • Resource Coordination (basic case management services) • Assists dental referrals for patients who do not qualify • Face-to-face interaction with contracted dental staff • Coordinates claims, billing, payment, prior authorizations • Patient and contracted dentist liaison– questions,

concerns, complaints • Manage quality program adherence

Logistics – Patient Flow • Patient registration with Dental Services

Coordinator – Referred to program by CHC staff or contracted

provider – Patient completes standard new patient paperwork,

household assessment, dental health history paperwork and the application for sliding fee scale

• DSC refers patient to contracted dental office • Contracted dental office contacts patient to

arrange appointment, reminder calls, etc.

Logistics – Patient Flow • Patient continues to work directly with

contracted dentist to make appointments – DSC assists with transportation, etc. if necessary.

• Contracted dental submits claims as if CHC is insurance/payer. – CHC verifies claim and requests corrections, etc. – CHC processes claims and bills insurance/patients.

• CHC pays out claims to contracted dentist.

Results • Program ran for nine months until contract

services between other CHCs and outside providers began to be denied by Medicaid.

• 459 encounters – 339 Medicaid (74%) – 120 Sliding Fee Scale (26%)

• One provider saw 64% of total encounters, 15% and 21% for the other two providers.

Reflections-Programmatic • What worked:

– Lots of communication with contracted providers – Dedicated staff member (Dental Services Coordinator) – Transportation assistance – Registration process

• What didn’t work: – Quality Assurance – very difficult to manage quality – DCS needed more decision making authority – Some confusion for patients (who’s my dentist?)

Reflections-Financial • What worked:

– Managing registration, and eligible patients very conservatively – 90% MA, 10% self-pay.

– Lakes staff submitting prior authorizations. – Claims going directly to our billing service. – Paying more for dental services than MA pays.

• What didn’t: – Needed tighter control over what services were

offered. – Different payment methodologies (per procedure

vs. per encounter) incented different treatment planning.

Currently… • Contracted Dental Program is suspended while

we fix the “didn’t work” issues. • We are still referring patients to these dentists

through referral contracts without enhanced reimbursement.

• We hope to resume contracts in 2013 that: – Provide patient choice – Are financially sustainable – Increase access to high quality care for adults – Are a win-win-win for patients, Medicaid and

dentists

Lessons Learned • Mutual trust is critical to success. • The Dental Services Coordinator needs to be able to make

programmatic and financial decisions. Too many people involved causes confusion.

• Quality and reporting requirements and protocols should be established together, agreed upon early, implemented immediately and maintained consistently. Do not underestimate the awkwardness of quality conversations between providers; or the cost of dealing with issues after the fact!

• Contracted providers should be paid by encounter (same payment methodology as CHC).

• Services provided should be limited. Dollar limits should be established for un-insured patients.

QUESTIONS?

Children’s Dental Health Project | 1020 19th Street NW, Suite 400 Washington, DC 20036 | 202.833.8288 | www.cdhp.org

Increasing Access to Dental Care Through Public/Private Partnerships:

An FQHC Handbook

Strengthening Oral Health in Ohio Summit May 10, 2013

Patrice Pascual, Executive Director

Children’s Dental Health Project


Mission: Creating and advancing innovative solutions to achieve oral health for all children.

Our Approach 1. Reduce dental disease burden 2. Improve access to high-quality dental care

Our Goals Prevent childhood tooth decay, because cavities are the result of a disease that is overwhelmingly preventable.

Promote solutions that are grounded in the best available research and support exploration when evidence is lacking

Engage policymakers and other decision-makers in addressing ongoing inequities in oral health and to implement cost-effective solutions.

Children’s Dental Health Project


What Happens in Childhood…Stays

Low-income adults line up at dawn for “Missions of Mercy” dental care event


“Moving the Needle” for OH

CDHP – and partners – in 2013

• ECC Simulation Model: Returns on intervention • FLUIDlaw.org: water fluoridation case law • State Oral Health Coalition tool • School-based sealant report by Dr. Mark Siegel • Medical / Dental Collaboration

– Perinatal Oral Health – awareness and change – Oral health “icebreaker” quiz

• Affordable Care Act • Medicaid and CHIP


Dental Coverage is Essential

1967: Congress created the Medicaid Early and Periodic Screening, Diagnosis, and Treatment program for low income children.

BUT, the pediatric benefit didn’t specify dental requirements for its first 22 years. 1997: Children’s Health Insurance Program (CHIP) implemented for children in working poor

households. BUT, CHIP didn’t include dental benefits for its first 12 years. 2010: the Patient Protection and Affordable Care Act (ACA) created to make coverage available

and affordable in small group and individual market. Deemed dental care for children an “essential benefit.”

BUT, some families may face challenges accessing an affordable dental benefit.

Today: Most children in the U.S. have a path to dental coverage.

Dental coverage increases dental utilization – expanded coverage means more will receive care.


Changes in Coverage

Source: Marko Vujicic, Ph.D., Health Policy Resources Center, American Dental Assn.


Changes in Dental Visits

Source: Marko Vujicic, Ph.D., Health Policy Resources Center, American Dental Assn.


National Health Center Data (HRSA, 2011)

• 1,128 Health Centers reporting

• Total patients: 20,224,752 Percent of total patients <12: 22.5% Patients who used dental services: 4,037,384 (20%)

• Total center visits: 80,027,696 Dental visits: 9,991,320 (12.5%)


Ohio Health Center Data (HRSA, 2011)

• 33 Health Centers reporting

• Total patients: 484,631 Percent of total patients <12: 22.4% Patients who used dental services: 91,850 (19%)

• Total center visits: 1,695,834 Dental visits: 223,104 (13.2%)


A Role for Public-Private Contracts?


2003: Original Handbook

• Created in 2003 with support from the Connecticut Health Foundation

• The Handbook and model contract intended as guidance, based on federal law and policy, for dentists and centers desiring to pursue the opportunities to expand access to dental services for health center patients

• Endorsed by National Association of Community Health Centers and American Dental Association

• No formal endorsement from HRSA or CMS; states remained skeptical


CHIP Reauthorization Act of 2009

• Following the release of the Handbook, confusion continued among CHCs and Medicaid agencies

• CDHP sought clarification through Congress • CHIPRA: Language included to assist in clarifying the practice

of contracting was legal “…the State will not prevent a Federally-qualified

health center from entering into contractual relationships with private practice dental providers…”


2010: Revised Handbook

• Revised in 2010, with support from the California HealthCare Foundation

• Updated Handbook reflects changes in Federal law and policy since 2003, including CHIPRA

• Provides background on how contracting works, includes a model contract, and offers step-by-step options for implementation

• Endorsed by National Association of Community Health Centers and American Dental Association


2011: Further Federal Clarification

March 25, 2011 CMCS Informational Bulletin: “…CHIPRA added a new section…which provides that a State may not

prevent a Federally-Qualified Health Center (FQHC) from entering into contractual relationships with private practice dental providers in the provision of FQHC services…also amended section 2107(e)(1)(B) of Title XXI by applying this same requirement to CHIP.”

Also answered the following questions: Question 1: How does section 501(d) affect State Medicaid and CHIP programs? Question 2: How will this provision be implemented? Question 3: What is the Health Resources and Services Administration’s (HRSA) role and

responsibility regarding the FQHC program?


Step 1: Obtain Dental Authority

• .


Step 2: Expand Dental Services

Dental Services authorized


Sample Contract

• Patient of Record / Patient Experience • Covered Services • Charges and Billing • Oversight • Liability • “Fit” (health center, provider and the practice)

Drafted by NACH’s outside counsel Reviewed by ADA, HRSA, NACH


Step 3: Contract Dental Services


Step 4: Management


Getting Started

The Handbook: www.cdhp.org/resource/FQHC_Handbook CMS Informational Bulletin:

http://downloads.cms.gov/cmsgov/archived-downloads/CMCSBulletins/downloads/CMCS-Info-Bulletin-March-2011-Final.pdf


The Ultimate ROI


Patrice Pascual

Children’s Dental Health Project [email protected]

202-417-3596

Thank You!

contract dental services · • we are responsible for all permanent charting, prior authorizations...

Documents