monica f. anderson, dds - national dental association · medicaid dental benefits medicaid covers...
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MonicaF.Anderson,DDSDentalBenefitsConsultant,AADCNationalDentalAssociation104thConventionDallas,TexasJuly23,2017
DiscussionTopics
q HistoryofMedicaid&CHIPinDentistryq BarrierstoCareq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends
Disclaimer:Thecontentofthislectureandopinionsexpressedarethoseoftheauthoranddonotrepresenttheofficialopinionsoftheconferencehost,theworkshopsponsor,oranycompanywithwhichIamaffiliated.
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
LikePullingteeth…
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HealthCareSafetyNet
“Healthcareprovidersthatdelivercareinavarietyofsettingstoadiversegroupofpeople.Theseprovidersincludepublichospitals,communityhealthcenters,localhealthdepartments,freeclinics…thatdelivercaretolow-income,vulnerablepatients.”-WakeForestUniversity
CreditJennyDowning/FLICKR
q HistoryofMedicaid&CHIPinDentistryq BarrierstoAccessq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
SocialSecurityActof1935
10RegionalOffices
CMS
Medicare Medicaid CHIP HIX
1in3AmericansisinaCMSProgram
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https://en.wikipedia.org/wiki/Social_Security_Acthttps://en.wikipedia.org/wiki/Medicaid
EssenBalHealthBenefits� Emergencyservices� Hospitalization� Pregnancy,maternity,newborncare� Mentalhealthandsubstanceusedisorder� PrescriptionDrugs� Labservices� Pediatricservices,includingoralcare(butadultdentalcareisnotcovered)
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
MedicaidDentalBenefitsMedicaidcoversdentalservicesforallchildenrollees(age18andyounger)aspartofacomprehensivesetofbenefits,referredtoastheEarlyandPeriodicScreening,DiagnosticandTreatment(EPSDT)benefitFederallymandateddentalbenefitsforchildrenmustminimallyincludeservicesfor:ü Reliefofpainandinfectionsü Restorationofteethü Maintenanceofdentalhealthhttps://www.medicaid.gov/medicaid/benefits/dental/index.html
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EPSDTandMedicalNecessityEarlyandPeriodicScreening,DiagnosticandTreatment(EPSDT)isamandatoryFederalchildhealthprogramforMedicaidrecipients,emphasizing� Screening� Earlydiagnosis� Necessarytreatment
UndertheMedicaidprogram,statesdeterminewhatbenefitsarecoveredandtheydefine“medicalnecessity”
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Children’sHealthInsuranceProgram(CHIP)InDenBstry
� CHIPisanoptionalMedicaidprogramdesignedforthechildrenofworkingfamilieswhoareuninsuredbutdonotqualifyforMedicaid(age20oryounger)
� CHIPcoverageisbasedonfamilysizeandincome� Coverageincludestreatmenttopreventdisease,restorefunctionandtreatemergencyconditionsperfederalpolicyguidelines
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q HistoryofMedicaid&CHIPinDentistryq BarrierstoAccessq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
AccesstoCare� 2000,theSurgeonGeneral’sreportemphasizedtoothdecayisthemostchronicailmentforchildren
� 2007DeamonteDriverdiesfromoralhealthcomplications
� 2017proposedchangeslikelywillnotexpandoralhealthcarebenefits
� Only32%ofU.S.dentistsinprivatepracticeacceptMedicaidpatients
� MillionsofchildrencoveredbyMedicaiddonotreceivedentalcareorroutineexams
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WhyBother?� “Toomuchredtape,brokenappointmentsandunappreciativepatients.”(Alaskadentist)� “Medicaidratesaresolow,theydon'tevencoveroverhead.”(Floridadentist)� “Thegovernmentshouldraisethereimbursementssotheyareatleastinlinewithinsurancecompanylevels.”(Nebraskadentist)� “Withallthedentistsbeingprosecutedandsomethrowninjaillatelyforwhatappeartobehonestcodingmiscodingmistakes….It'sjusttoorisky.”(Texasdentist) http://thewealthydentist.com/surveyresults/084-dental-medicaid-patients.htm
Reason#1DentalDiseaseisTooPrevalent
AndItIsPreventable
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Reason#2MedicaidandCHIPcanwork
foryourpracBce
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SeTngReimbursementRates� TheStatesdecidewhatiscoveredandthereimbursement/encounterrates
� Commercialinsurancerates,datafromhealthplans,stakeholderinput,andotherfactorsareusedbyanactuarialfirmtodeveloprates
� Alwayssubmityourregularfees,nottheallowedfees
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Administrators
� Moststatescontractwithvendors/MCO’s/TPA’stoadministertheirprograms
� StatespayMCO’sacapitationrateper-member-per-month(PMPM)tooperationalizethesepublicfundedbenefitplans(managedcare)
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ThirdPartyAdministrators(TPA)Statespaythirdparties(businesses)toadministerthedentalbenefits.TPA’sprovidecustomerservice,claimsprocessing,clinicalmanagement,andmaintaintheprovidernetworkTwoprimarymodelsforfundingStateprograms:1. AdministrativeServicesOnly(ASO)-TPAispaida
fee(PMPM)toadministertheprogram.Claimsarepaidusing“dedicatedfunds”fromthestate.
2. FullyInsured(RISK)-TheStatepaysafixedamountfortheadministrativeservicesandpaymentofclaims
Ref:Smithwick,C.,DentalBenefitsAGuidetoManagedPlans,3rded.,2010
ReimbursementRates
April2015–“RepublicanGov.MikePenceannouncesIndiana’sMedicaidexpansionplaninJanuary.PartofthatplancallsforraisingreimbursementratestotrytopersuadedoctorstoacceptMedicaidpatients.Fourteenotherstatesaredoingthesame.”(AP)
Credit©AP
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FeeSchedules� Acomprehensivelistofmaximumallowablefeesonafeeforservicebasis
� Feesmayvarybyprovidertype,specialty,placeofservice,clienttype,orotherfactors
� Refertotheadministrator’scurrentMedicaidProviderProcessingPolicyManualforcoveredservices.
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FreetransportaBon=DecreasedNoShows&
Overbooking
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LanguageBarriersMedicaidprovidesinterpretersforfreeandfreerelayserviceformemberswhoarehearingorspeechchallenged
q HistoryofMedicaid&CHIPinDentistryq BarrierstoAccessq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends
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KeyConcepts� LeastExpensiveAlternativeTreatment(LEAT)akaLeastExpensiveProfessionallyAcceptableAlternativeTreatment(LEPAAT):theleastcostlyacceptabletreatmenttorestorefunction
� ManagedCare:Provisionofbenefitsbymanagingutilizationandcostusingcontractedproviders,reducedprices,pretreatmentreview,utilizationfunctions,auditsandplandesign.
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ClaimsAdjudicaBonProcess� Claims,priorauthorizations(PAR)receivedandadjudicatedelectronically.
� Manyaresystematicallyapproved,reviewnotrequired
� ClaimsReviewers(asst’s,hygienists,nurses)determinewhatcanbeapprovedforpaymentwithoutDentalConsultantReviewusingalgorithmsbasedonpolicy
� ClaimsReviewerssendhighcostprocedures,miscellaneouscodes,medicalcodes,complexproceduresandpossibledenialsforclinicalreview.
DentalBenefits:AGuidetoManagedPlans,3rded.Smithwick2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
RoleofTheDentalConsultant/Reviewer
Ø Plansdonot/cannotofferfinancialincentivestoconsultantstodenyappropriate,necessarytreatment
Ø Qualified,licenseddentistsmakedecisionstoclinicallydenyorapprovecoverageusingevidencebasedguidelines,regulations,processingpoliciesandprofessionaljudgment
Ø Peertopeercalls,StateFairHearings,ReviewGrievancesØ Monitorindustrychanges,bestpractices,&latestresearch
Ø DetectpotentialFraud,Waste,andAbuse(FWA)
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ClinicalGuidelinesAAPDGuidelinesonmaxillaryfrenectomy–midlinediastemawiderthan2mm,preventorthodonticrelapse,traumaticpullonthegingiva,difficultynursing…butalsoincludestheword“optionsvary”
OpensourceImagesFrenectomytoday.com2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
StandardsofCareLegalDefinition:Whatareasonableandprudentdentistwoulddounderthesameorsimilarcircumstances’
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AutomaBon=Faster,Be^er,StrongerClaimsProcessing
� InvestinIT(EHR)tosavetimeandmoney� Submitclaimselectronically� Submitattachments(periocharting,xrays)usingFastAttachbyNEAorasimilarsystem
� Feweradmindenials,fasterreimbursement,lesspaper,bettersecurity
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DigitalRadiography
Ref:http://ffden-2.phys.uaf.edu/104_2012_web_projects/Elizabeth_Goldsmith/Digital_Radiography_files/shapeimage_3.jpg
APictureIsWorthAThousand…
Ref:Dental%20Implant%20Scann%20Proposal
CodeonDentalProceduresandNomenclature(CDT)
� CDTprocedurecodesarecreatedandownedbytheADA
� ©2017ADA.AllRightsReserved� CDT2017isthemostcurrent� OnlyHIPAA-recognizedcodesetfordentistry� Accuratecodesincreasereimbursement
q HistoryofMedicaid&CHIPinDentistryq BarrierstoCareq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends
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AGOODNARRATIVE:
� Toothspecificanddescribesthesymptomsthatarebeingexhibitedbythemember� Ifthememberisorhasbeenonantibiotics,includenameanddosage� Ifthememberisorhasbeenonpainkillersforanextendedperiodoftime,includethisinformation� Ifthemember’sageorbehaviorcouldbeadeterminingfactor,elaborate� Ifthereisanysymptompresentthatisnotidentifiablebyviewingthex-ray,thisshouldbeincluded
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onicaFAnderson,
DDS.C
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HIPPAA-FederalLegislaBon
HealthInsurancePortabilityandAccountabilityActof1996(HIPAA)includedtheseimportantprovisions-q RequiredtheU.S.DepartmentofHealthtocreatestandardsforelectronichealthcaretransaction
q Establishedstandardsforthesecurityofhealthdata
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CommonHIPAAViolaBons
� Notadheringtothepatient’sauthexpirationdate� Failuretopromptlyreleasecopiesofmedicalrecords� Improperdisposingofmedicalrecords� NosignatureonHIPAAforms� Releasinginfotoanunauthorizedparty� Releasingunauthorizedhealthinformation� Releasingwrongpatient’sinfo� Formsareinvalidwithouta“righttorevoke”clause� UnprotectedstorageofPHI
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BeforeyouCallthePlan,WhyWasTheProcedureDenied?� Isitaclinicaldenialoranadministrativedenial?� Didyousubmittheproperdocumentation?� Checkthefrequency,agelimitations� Eligibility?� Timeliness?� Non-diagnosticradiographs,preandposttxpa’smayberequired
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ResubmitorAppeal?� Thereisadifference-doyouneedtosubmitrequireddocumentationordoyouneedclinicalreview?
� AlwayssendALLtherequireddocumentationwitheachsubmission.Includetheclaim,txnotes,diagnostictests,intraoralphotosandpre/postradiographseachtime.
� ReferenceanypreviousauthorizationsorcommunicationinBox35.Donotonlysend“requestedmaterial”i.e.postoppaoranarrative.Itmaynotgetattachedtotheprevioussubmission.
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PeertoPeerCalls
� Licensed,experienceddoctors
� Beprofessional� Listencarefullyandaskquestions
� Speaktothedentalconsultantpersonally� Reviewwhatwassubmittedbeforeyoucall
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AppealsandFairHearings� Theplanshavespecificproceduresformembersandproviderstoappealclinicaldecisions
� Refertotheprovidermanualorportalfortheprocess.Itisdifferentforprovidersandmembers
� Usethecorrectform.DonotsendanastygramtotheDentalConsultantwhodeniedtheclaim
� SubmityourappealorgrievancewithintheTPA’sdeadlinewhichbeginsfromthedateyoureceivetheadversedecision
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
q HistoryofMedicaid&CHIPinDentistryq BarrierstoAccessq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
TheBusinessofHealthCare
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Fraud:Actionsthat“knowinglyandwillingly”schemetodefraudforthepurposeofobtainingmoneyorproperty.
Intentionallysubmittingfalseinformation.
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UnBundling
Codeforwhatyoudo, dowhatyoucodedfor.
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Coding� ForcodeD2150,twocontiguoussurfaces,#3MOshouldbeonasingleline
� If#3presentswithanMOandaseparateDO,thesecodesshouldbelistedontwolinesofthesameclaimform.
� Insurancewilllikelyallowa3-surfacerestorationiftheyareformedonthesamedayorwithinashorttimeperiod.
http://www.dentaleconomics.comvolume-93,issue-3
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Waste:
Overutilization,unnecessarycosts,misusebutnotcriminallynegligent
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Abuse:
Paymentwithnolegalentitlement.Actionsthatareimproper,inappropriate,outsideacceptablestandardsofprofessionalconductormedicallyunnecessary.
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
q HistoryofMedicaid&CHIPinDentistryq BarrierstoAccessq ClaimsAdjudicationProcessq BestPracticesq Fraud,Waste,andAbuseq PayforPerformance/Trends
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.
Importanttrends
� QualityImprovementPrograms/Processes� ImprovingOralHealthCareDeliveryModels� CommunityPartnerships� PerformanceImprovementProjects(PIP)forStatesandHealthPlans
� RiskAssessments
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“Improvedquality.Lowercost.”Dr.PatrickConway,CMSDeputyAdministratorforQualityandInnovation
Bettercare.Lowercost.PatientCentered.Betterhealth.
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PayForQuality(P4Q)� Appliestostates,plans,andpractices� AdministratorsmustmeetState/Federallymandatedmetrics,turnaroundtimes,qualitymeasures
� Evidencebased,datadrivencoordinatedcareisthenewmodel
� Movingawayfromacutecaretolongtermoutcomes,patientcentriccare
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DentalQualityAlliance(DQA)ThemissionoftheDQAistoadvanceperformancemeasurementasameanstoimproveoralhealth,patientcareandsafety.Objectives� Toidentifyanddevelopevidence-basedoralhealthcareperformancemeasuresandmeasurementresources.
� Toadvancetheeffectivenessandscientificbasisofclinicalperformancemeasurementandimprovement.
� Tofosterandsupportprofessionalaccountability,transparency,andvalueinoralhealthcare.
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NewWorkforceModelsforCareDelivery
� ExpandedFunctionDentalHygienists
� DentalTherapists
� Remote/Teledentistry
� CommunityBasedClinics
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DentalTherapistsByusingdental
therapists,statesareprovidingabasichealthservicefor
vulnerablecommunities…
Minnesotawasthefirststateto
authorizethedentaltherapyprofession
eightyearsago.-JohnGrant,PewCharitableTrust
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CommunityPartnerships
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IntegratedHealth� Employeebenefitssystemthatconnectsmedicalandnonmedicalbenefitsandrecord(dental,pharmacy,vision…)
� Coordinatedapproachtoimprovingoverallhealth� CaseManagement� Bundleddentalandmedicalinsuranceplans
Accordingtothe2017AnthemIntegratedHealthCareReport,60%ofmorethan200surveyedemployersareeitherimplementingoractivelyconsideringimplementingintegratedhealthcarebenefitplans.
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� www.drmOeanderson.com� NeedaSpeaker?Convention,LocalChapter,StudyClub,AssociationMeetings…
� Emailme:info@drmOeanderson� Twitter~@drmOeanderson
Questions?Comments?
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ThankYou!Enjoytheconference!
2017CopyrightMonicaFAnderson,DDS.ConfidentialandProprietary.