The Health and Human Services Commission in February 2009 asked the individuals working on the new Medicaid orthodontic benefit policy to review whether or not a board certified orthodontist should review each and every prior authorization request for orthodontic treatment.
In fact, it was recognized as one of the major issues. Per the document in the recent court filing by Xerox, it was issue #3 out of 5 to be resolved in the new policy for the Medicaid orthodontic benefit.
Reviewed whether to use a board certified orthodontist for prior authorization requests
The document states:
Initial Recommendation: All submitted orthodontic prior authorizations will be reviewed by a board certiﬁed Texas orthodontist through the Health and Human Services Commission claims administrator contractor(s) responsible for dental claims review and payment to determine if the case qualiﬁes for orthodontic treatment as outlined by orthodontic policy.
However, the change was opposed by the sheer economics of the scene because both TMHP/Xerox and HHSC knew exactly how many prior authorization requests were being made each month.
Costs would have required a change to the TMHP/Xerox contract
The following is in the document:
02/ 13/2009: E- mail from Special Project Director, “Requirement to have all orthodontics requests reviewed by a board certiﬁed orthodontist- This will have immense Operational impacts for PA/MedicaLDirectors and.require a COR [change order request – a COR is used to amend the current contract or scope of project] witl1 considerable expense to HHSC. Currently, PA receives an average between 9,000 and 10,000 requests each month, of‘ these 90-95% are orthodontics.
Currently, less than 10% of requests are reviewed and that 100% review would require signiﬁcant more Medical Director and PA staff which would need to be addressed in a COR due to the Operational impact.”
Less than a week later, the TMHP representative tables the request for a week but it appears it was never further taken up.
<02/18/2009> – BIL [Benefits Initiative Lead] Meeting -Special Project Director requested to discuss the overwhelming impacts that will happen if only board certiﬁed orthodontists are the only reviewers for orthodontic prior authorizations. At this time, the PA department receives roughly 9,000 -10,000 request a month for dental services which approximately 90 -95% are for orthodontics. This would require a signiﬁcant amount of extra staff and cost; that would require a COR which is not part of the medical policy development. TMHP BIL recommends that we table this issue until the next workgroup scheduled for Tuesday.
Final recommendation is to restrict who practices Medicaid orthodontics
This is because the final recommendation for the issue is to create four new levels of orthodontic treatment and to restrict who can practice Medicaid orthodontics.
Final Recommendation: Provider enrollment will need to create a new certiﬁcation for Portability that will be added to each of the providers that are eligible for a Portability Permit through the Board of Dental Examiners.
The requirements will be based on Provider Types: Dentists (D.D.S., D.M.D.) who want to provide any of the four levels of orthodontic services addressed in this policy must be enrolled in THSteps and must have the qualiﬁcations listed in Table A [as below] for the relevant level of service. Dentists must provide proof‘ of qualiﬁcations to TMHP Provider Enrollment prior to the submittal of their ﬁrst prior authorization request associated with this policy.
Provider Requirements – Level of Orthodontic Service Qualifications
Level One or Two – Completion of pediatric dental residency; or a minimum of 200 hours of continuing dental education in orthodontics.
Level One, Two Three, or Four – Dentists who are orthodontic board certiﬁed or orthodontic board eligible.
The new levels of the program will be published in a subsequent story.
Knew HLD scoring and PA process needed to be reviewed
Relatied to HLD scoring and the prior authorization process, Issue #1 in the drafting of the new policy consisted of the following prior issues.
5.1 _ Prior Issues
Identified Issue: The comprehensive review has been on hold from 09/19/2007-02/05/2009.
Related Issues: Include other issues that may have been created as a result of this issue, or have cross implication.
Initial Recommendation: Issues from previous tracking document:
- The issue discussed is allowing the open—ended reimbursement of replacement brackets though the non-standard use of CDT code D8690 sets Medicaid up for potential misuse whether intentionally or unintentionally.
- Implement the pending policy (which includes the authorization changes previously sent out in provider communication).
- For the general dentist to treat the dentist would need 200 hours of continuing education and present 20 cases for peer review. Aﬁer that the provider would he able to submit cases with the peer review doing spot checks.
- Review conflict of prior authorizations criteria of procedure codes D5951-D5960 as listed in the Therapeutic policy and the Orthodontic policy.
- Make procedure codes D8070 and W-D8090 beneﬁts of Texas Medicaid program 100/200.
- Review PA processes as to if the criteria need to be strengthened.
- Statement added to the Transfer of Services section in the policy, “Authorization issued to a provider for orthodontic services is not transferable to another provider. The new provider must request a new authorization to complete the orthodontic treatment initiated by the original provider. The new authorization will only be for the completion of the original treatment plan“.
- Local codes might need to be removed from provider manual and claims.
- The Handicapping Labio-Lingual Deviation (HLD) Index scoring sheet needs to be re-evaluated.
- Review the policy of paying for 2 out of every 10 cases submitted that are denied.
- Need to develop new policy with the changes identiﬁed during the stakeholder’ meetings.
No policy changes made
So it was noted back in 2009 that the prior authorization process and HLD scoring needed to be tightened up and that was part of the reason for the new policy which was never implemented. However, again there is no mention of fraud, waste or abuse by providers.
The full document can be downloaded here.Exhibit-F-board-certified-1