TDMR has learned that a number of dental providers have reported being placed on payment hold by MCNA for “willful misrepresentation or abuse of claims.”
Payment holds placed for mistakes and missing paperwork
In these reports, dentists claim that MCNA’s actions appear eerily similar to the behavior of the Texas Health and Human Services Commission Office of Inspector General from 2012 to 2015—namely, that MCNA is indiscriminately using payment holds in response to audits that reflect, at best, simple charting mistakes and missing paperwork.
The dentists state that the audits began like any other with MCNA requesting patient records. But the providers are never given any feedback on the audit results nor are they told MCNA has any concerns regarding the audit findings.
Instead, MCNA network providers simply receive notice of a payment hold.
Notice of hold not received for days or weeks
That notice usually arrives in the mail days or weeks after the hold has been actually instituted on the provider.
MCNA’s approach in these cases appears even colder than the old OIG. The providers are given no opportunity to engage in conversations with MCNA regarding the allegations nor are they given the opportunity to supplement documentation prior to the imposition of the payment hold.
The payment hold letters do not indicate what amount MCNA believes has been improperly paid. The letters often do not reveal the audit results for each patient reviewed.
Instead, the MCNA letter usually gives just three examples of the “willful misrepresentation or abuse [that] exists to support the payment hold.”
Providers have reported these common examples:
“Lack of documentation for the administration of Nitrous Oxide so MCNA is unable to substantiate standard of care.”
Providers are reporting that this error is often just a dentist forgetting to record the start and stop times for the administration of nitrous oxide. Failing to record start and stop times is a technical violation of the Texas dental board rules, but dentists are reporting that often other documents in the patient chart prove that the service was both necessary and otherwise done properly.
“Billed and received reimbursement for service not documented in the clinical notes. MCNA cannot confirm that the services were provided.” and “Billed and received reimbursement for dates of service missing from the clinical notes as having been rendered. MCNA cannot confirm that the services were provided.”
Providers complain that intermittent recordkeeping mistakes are being elevated to something that is not merited. For example, some providers noted that even if the clinical notes did not reflect a service was provided, other documentation in the patient file, such as post-procedure x-rays, proved that the service was provided.
“Billed and received reimbursement for x-ray images not in file.”
Providers report concern that sporadic recordkeeping errors might result in a payment hold.
“Billed for and received reimbursement for services rendered by non-credentialed providers at the time services were provided, but billed under credentialed providers.”
Dental providers may not know that MCNA’s contract with Medicaid requires that MCNA comply with Texas Insurance Code Chapter 1452, Subchapters C, D, and E, regarding expedited credentialing and payment of providers who have joined established medical groups or professional practices that are already contracted with MCNA. TDMR has consistently received complaints that MCNA does not appear to be complying with those obligations because MCNA takes 90 -150 days to credential dentists even when the location is already an MCNA network provider. Providers also might not realize that those same insurance code provisions appear to require that MCNA be able to process claims from any “credentials-pending” provider within 30 days of the provider’s application.
We sent a copy of this story to MCNA’s Vice President of Operations Shannon Boggs-Turner and she provided us with this response.
MCNA is committed to maintaining the integrity of the Medicaid and CHIP programs we serve through provider audits and policy reviews. We identify and monitor program vulnerabilities, and provide support and assistance to HHSC to deter, reduce, and eliminate fraud, waste and abuse. Sophisticated analytics and the observation of our Texas licensed dental reviewers are used to identify providers with atypical practice and/or billing patterns. Once a provider or group is identified, a chart audit is conducted. These reviews are designed to identify payment errors in billing, verify that medically necessary services were rendered, and ensure that services were provided in a manner that meets professionally recognized care standards, and in accordance with State and federal laws, regulations, and plan requirements. Providers are notified of the results of the chart audits, and in certain instances a payment hold may be placed.
All participating providers are aware of our responsibility to ensure the integrity of the programs we serve. MCNA’s Provider Manual states the following:
If MCNA has credible evidence of fraud, willful misrepresentation, or abuse under the requirements set forth by the Texas Medicaid and CHIP dental programs, MCNA shall have the right to impose claims payment suspensions on a provider and a facility. Allegations are considered to be credible when they have indicia of reliability and MCNA has reviewed all allegations, facts, and evidence carefully and acts judiciously on a case-by-case basis. The suspension of payment action will be temporary and will not continue if MCNA determines that there is insufficient evidence of fraud, willful misrepresentation, or abuse by the provider.
Any provider who has been placed on payment hold is given an opportunity to appeal any findings they dispute. MCNA works to evaluate the appeal and provide a final resolution to the matter as expeditiously as possible.
In terms of credentialing, MCNA is not experiencing any delays in processing complete provider applications. We do receive incomplete applications from providers where missing information must be gathered before the application can be processed. In these instances our dedicated call center team reaches out via phone, email, or letter to the office and makes them aware of what is needed to complete the application. Once a completed application is received, the typical turnaround time for the determination is 30 days. If a provider has any issues with the credentialing forms or questions about the process, we encourage them to contact their MCNA Provider Relations Representative for assistance.
We would also like to take this opportunity to encourage providers who have not completed their re-enrollment with TMHP to do so as quickly as possible. Providers must complete the re-enrollment with TMHP in order to continue participation as a Medicaid provider for MCNA due to the requirements of the Affordable Care Act. Here is a link to TMHP’s website page regarding this effort:
The only thing we can say at this time is that former Inspector General Doug Wilson used to say the same things on payment holds.
MCNA payment hold appeal window shorter than state statute
One thing is certain – the timeframe to request an appeal of an MCNA payment hold is only 10 days. This is even shorter than the timeframe set for the state in statute. So providers should contact legal counsel to preserve their rights.
Let us know
As a service to its members and the dental Medicaid provider community, TDMR is interested in any similar stories from providers in Texas. Serving the neediest of Texans requires diligence from all angles. If managed care organizations like MCNA are doing things that reduce patient’s access to care or reduce patient’s benefits, TDMR wants to know.
We invite other dentists who are faced with this problem to contact us via our Medicaid Alert form on our website or to email us at firstname.lastname@example.org.