Category Archives: Orthodontia Services
I’ve blogged before about the shortage of dentists for Medicaid recipients. Just see my post “Medicaid Expansion: BAD for the Poor” to read about Deamonte Driver’s story and why he died due to not being able to find a dentist accepting Medicaid. But, today and yesterday, I decided to conduct my own personal investigation.
(First, let me assure you that this blog is not condemning dentists for not accepting Medicaid recipients. I am informatively (I know, not a word) pointing out the facts. We cannot expect dentists to accept Medicaid when the Medicaid reimbursements dentists receive cannot even cover their costs.)
I googled “Raleigh dentist” and called, randomly, 20 dentists listed. I said the same thing to each receptionist, “Hi. I was wondering whether you accept Medicaid.” Every office had a receptionist answer (no recording asking whether I wanted to continue in English or Spanish). Every office receptionist was very sorry, but the dental practice did not accept Medicaid. 0. Zero out of a random 20.
So I went on North Carolina Department Health and Human Services’ (DHHS) website for dental providers. I pulled up the dental providers, and, lo, and behold, 44 pages were full of dental providers for Medicaid recipients. Literally, 1,760 dental providers are listed (44 pages times 40 lines per page). (However, some practices are listed more than once, so this number is an approximation).
I thought, Wow. Tons of dentists in North Carolina accept Medicaid. Then I looked again. On the far right side of the chart, there is a space for whether the dental practice is accepting new clients. Roughly 1/2 of the listed dental providers are NOT accepting new Medicaid clients.
I called a few of the dentists in Wake County accepting Medicaid. Again, I asked whether they accepted Medicaid. One stated, “Yes, but not at the moment.” Another said, “Yes, but only for children 21 and under.” Another gave a blanket, “Yes.
So that’s Wake County…what about more rural counties?
I called a few dentists in Union County. Two practices did not answer. One dental practice answered and gave me a “Yes.” According to the DHHS chart of Medicaid-accepting dental providers, 20 dentists in Union County accept Medicaid. 4 of which are not accepting new clients and one dental practice is listed as the health department. There are no orthodontists in Union County accepting Medicaid.
The phone numbers for two dental providers in Swain County were changed or disconnected. There are only 3 dental providers in Swain County. There are no orthodontists in Swain County.
There is only 1 dental provider accepting Medicaid in Pamlico County. According to the DHHS chart, the one dental provider is not accepting new patients. There are no orthodontists in Pamlico County.
Polk County lists 3 dentists accepting Medicaid, but not one of the dentists are accepting new clients. There are no orthodontists in Polk County.
Mitchell County has 4 dental providers acccepting Medicaid. But 3 of those dental practices are not accepting new clients. There are no orthodontists in Mitchell County
In Clay County, the only dental practice accepting Medicaid recipients is the health department.
In Ashe County, there are 3 dentists listed that will accept Medicaid. Only 2 are accepting new clients, one of which is the health department. There are no orthodontists in Ashe County.
In Alamance County, there are 4 dentists listed by DHHS who will accept Medicaid patients. The first one I called (an orthodontist) told me that they accepted Medicaid patients only from certain general dentists. The second one was not accepting new patients. The third one (also an orthodontist) informed me that Medicaid does not cover orthodontia services for Medicaid recipients over 21 (I must sound old!!!) The fourth dental practice’s voicemail informed me that the office is only open Wednesdays and Thursdays for limited times. Of the 4 dental practices accepting Medicaid, 3 were orthodontists, one did not accept new clients. The only general dentist (pediatric) only practiced in the local office two days a week.
Shortage of dentists accepting Medicaid? You decide.
After talking with the Office of Administrative Hearings (OAH) today and learning that, in the past 30 days, there have been 15,000 Medicaid appeals filed, I realized how important these Tips to Avoid Medicaid Recoupment may be. Granted, I am sure most of those Medicaid appeals are Medicaid recipients appealing denials of services, but, still, that is a lot of appeals!!
Tip #8: Always keep every revised version of whichever DMA Clinical Policy applies to your practice.
For example, if you provide orthodontia services to Medicaid recipients, then you should have every version of Clinical Policy 4B, starting when you started providing orthodontia services until the present.
If you have not this, never fear, you can go to The WayBack Machine, a website that keeps an archive of certain websites, including the material found on the website at different time periods. The WayBack Machine has archived the NC DMA websites over time.
Keeping every revised version of the applicable Clinical Policy will help health care providers avoid Medicaid recoupments, IF, and only IF, each time a new revised version is published, go through both the replaced version and the newly updated version page by page. Compare the old version to the new version. Find every word that was changed or sentence that was added, or additional criteria added. Highlight, on the new version, all the additional words. On the new version, mark where words or sentences have been deleted.
Doing this exercise will do two things: (1) the health care provider will be intimately knowledgable about the Clinical Policy (which is always helpful); and (2) the health care provider will know which sections or criteria were most important to the State. Wherever a change occurred, it is due to something. Usually you can figure it out. For example, if the new version of Clinical Policy 4B requires an additional criterion of the Medicaid recipient, in order to receive braces, to demonstrate a mental health diagnosis caused by crooked teeth (I’m making this up), then one could deduce that too many Medicaid recipients received braces in the past and that the State is trying to make it more difficult to receive braces.
Highlighting the changes in the new policies will help health care providers proactively avoiding Medicaid recoupments because the health care provider will understand each new criterion or hoop to jump through for the upcoming Medicaid claims.
However, doing this exercise will also help the health care provider who has received an audit and received the Tentative Notice of Overpayment claiming the provider owes money to the State. This is how: The Medicaid audits are auditing claims from 2009-2010 (usually). The Clinical Policies have changed immensely over the years. Many policies are more stringent now than in the past. The people conducting the Medicaid audits, often, in my experience, audit the health care provider with the current Clinical Policy in place now, not the Clinical Policy from the applicable time period. This results in incorrect audits and incorrect results.
Know the policies. Know the changes to the policies. Avoid Medicaid recoupments.