Category Archives: Clinical Policy No. 4B
The story of The Three Billy Goats Gruff tells a tale of 3 billy goats, one puny, one small, and one HUGE. The first two billy goats (the puny and small) independently try to cross the bridge to a green pasture. They are blocked by a mean troll, who wants to eat the billy goats. Both billy goats tell the troll that a bigger billy-goat is coming that would satisfy the troll’s hunger more than the puny and small goats. The troll waits for the HUGE billy-goat, which easily attacks the troll to his death.
The moral: “Don’t be greedy.”
My moral: “You don’t always have to be HUGE, the puny and small are equally as smart.” – (They didn’t even have to fight).
The majority of Medicaid cards do not have expiration dates. Though we have expiration dates on many of our other cards. For example, my drivers’ license expires January 7, 2018. My VISA expires April 18, 2018.
Most Medicaid cards are annually renewed, as well. Someone who is eligible for Medicaid one year may not be eligible the next.
Our Medicaid cards, generally, have an issuance date, but not an expiration date. The thought is that requiring people to “re-enroll” yearly is sufficient for eligibility status.
Similar to my CostCo card. My Costco card expires annually, and I have to renew it every 12 months. But my CostCo card is not given to me based on my personal circumstances. I pay for the card every year, which means that I can use the card all year, regardless whether I move, get promoted, or decide that I never want to shop at CostCo again.
Medicaid cards, on the other hand, are based on a person’s or family’s personal circumstances.
A lot can happen in a year causing someone to no longer be eligible for Medicaid.
For example, a Medicaid recipient, Susan, could qualify for Medicaid on January 1, 2015, because Susan is a jobless and a single mother going through a divorce. She has a NC Medicaid card issued on January 1, 2015. She presents herself to your office on March 1, 2015. Unbeknownst to you, she obtained a job at a law office in February (Susan is a licensed attorney, but she was staying home with the kids when she was married. Now that she is divorced, she quickly obtained employment for $70,000/year, but does not contact Medicaid. Her firm offers health insurance, but only after she is employed over 60 days. Thus, Susan presents herself to you with her Medicaid card).
If Susan presents to your office on March 1, 2015, with a Medicaid card issued January 1, 2015, how many of you would double-check the patients eligibility in the NCTracks portal?
How many would rely on the existence of the Medicaid card as proof of eligibility?
How many of you would check eligibility in the NCTRacks portal and print screen shot showing eligibility for proof in the future.
The next question is who is liable for Susan receiving Medicaid services in March when she was no longer eligible for Medicaid, but held a Medicaid card and, according to the NCTracks portal, was Medicaid eligible??
- You, the provider?
Do you really have to be the HUGE billy goat to avoid troll-ish recoupments?
Susan’s example is similar to dental services for pregnant women on Medicaid for Pregnant Women (MPW). MPW expires when the woman gives birth. However, the dentists do not report the birth of the child, the ob/gyn does. Dentists have no knowledge of whether a woman has or has not given birth. See blog.
MPW expires upon the birth of the child, and that due date is not printed on the MPW card.
I daresay that the dentists with whom I have spoken have assured me that every time a pregnant woman presents at the dental or orthodontic offices that an employee ensures that the consumer is eligible for dental services under MPW by checking the NCTracks portal. (Small billy-goat). Some dentists go so far to print out the screenshot on the NCTracks portal demonstrating MPW eligibility (HUGE billy-goat), but such overkill is not required by the DMA Clinical Coverage Policies.
If the clinical policies, rules, and regulations do not require such HUGE billy-goat nonsense, how can providers be held up to the HUGE billy-goat standard? Even the puny billy-goat is, arguably, reasonably compliant with rules, regulations, and policies.
NCTracks is not current; it is not “live time.” Apparently, even if the woman has delivered her baby, the NCTracks portal may still show that the woman is eligible for MPW. Maybe even for months…
Is the eligibility fallacy that is confirmed by NCTracks, the dentists’ fault?
Well, over three (3) years from its go-live date, July 1, 2013, NCTracks may have finally fixed this error.
In the October 2015 Medicaid Bulletin, DHHS published the following:
Attention: Dental Providers
New NCTracks Edits to Limit Dental and Orthodontic Services for Medicaid for Pregnant Women (MPW) Beneficiaries
On Aug. 2, 2015, NCTracks began to deny/recoup payment of dental and orthodontic services for beneficiaries covered under the Medicaid for Pregnant Women (MPW) program if the date of service is after the baby was delivered. This is a longstanding N.C. Medicaid policy that was previously monitored through post-payment review.
According to N.C. Division of Medical Assistance (DMA) clinical coverage policy 4A, Dental Services:
For pregnant Medicaid-eligible beneficiaries covered under the Medicaid for Pregnant Women program class ‘MPW,’ dental services as described in this policy are covered through the day of delivery.
Therefore, claims for dental services rendered after the date of delivery for beneficiaries under MPW eligibility are outside the policy limitation and are subject to denial/recoupment.
According to DMA clinical coverage policy 4B,Orthodontic Services:
Pregnant Medicaid-eligible beneficiaries covered under the Medicaid for Pregnant Women program class ‘MPW’ are not eligible for orthodontic services as described in this policy.
Therefore, claims for orthodontic records (D0150, D0330, D0340, and D0470) or orthodontic banding (D8070 or D8080) rendered for beneficiaries under MPW eligibility are outside of policy limitation and are subject to denial/recoupment.
Periodic orthodontic treatment visits (D8670) and orthodontic retention (D8680) will continue to be reimbursed regardless of the beneficiary’s eligibility status at the time of the visit so long as the beneficiary was eligible on the date of banding.
Seriously? “Now I’m coming to gobble you up!!”
August 2, 2015, is over two years after NCTracks went live.
In essence, what DHHS is saying is that NCTracks was inept at catching whether a female Medicaid recipient gave birth. Either the computer system did not have a way for the ob/gyn to inform NCTracks that the baby was delivered, the ob/gyn did not timely submit such information, or NCTracks simply kept women as being eligible for MPW until, months later, someone caught the mistake. And, because of NCTracks’ folly, the dentists must pay.
How about, if the portal for NCTracks state that someone is eligible for MPW, then providers can actually believe that the portal is correct??? How about a little accountability, DHHS???
If you take MPW and want to avoid potential recoupments, you may need some pregnancy tests in your bathrooms.
DHHS is expecting all dentists to be the HUGE bill goat. Are these unreasonable expectations? I see no law, rules, regulations, or policies that require dentists to be the HUGE billy goat. In fact, the small and puny may also be compliant.
“You don’t always have to be HUGE, the puny and small are equally as smart.”
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.