Last week, TDMR filed a complaint with the Texas Health and Human Services Office of Inspector General over the continuing complaints received by TDMR about the unacceptable delays in the credentialing of Medicaid dentists, particularly relating to the need to quickly credential substitute or emergency dentists in multiple practice offices.
Credentialing delays unacceptable
The complaint was filed via the OIG’s Fraud, Waste and Abuse Complaint online portal. The fact of the matter is simply that these unacceptable delays are hurting the delivery of needed dental treatment to Medicaid patients and causing an incredible strain on practices This is creating waste in the Medicaid dental program by either sheer incompetence or design and needs to be investigated by an outside agency such as OIG to get the root of the problem.
SMILED Act shows national concern over credentialing issues
The American Dental Association, along with other major dental organizations, as previously reported, are working at the federal legislative level to reduce administrative burdens on Medicaid dentists by promoting the SMILED Act, H.R. 1422, the Strengthening Medicaid Incentives for Licensees Enrolled in Dental Act, including credentialing.
No updates provided by OIG
Following is the text of TDMR’s complaint, which is limited to 7,500 characters by the online report form, and the acknowledgment of the receipt of the complaint.
Unfortunately, OIG does not provide updates on the progress or status of complaints.
Texas Dentists for Medicaid Reform.org is reporting a situation that has been going on for years and is creating delays in dental patient care and creating enormous treatment problems for dental providers through up to six and more month delays. The situation is the credentialing of emergency/substitute/new dental providers with TMHP and then the various dental maintenance organizations. This situation is causing waste and abuse of the Medicaid system in Texas.
We have written several articles about this continuing detrimental problem for providers and patients.
Important Excerpts from those articles:
Article 1. A major complaint is the extreme length of time it takes to credential dentists who are needed for emergency or substitute situations for a new location even though they are already credentialed for others in the same practice. The need is immediate and unpredictable, yet the powers that be have no sense of urgency or care.
The situation is best explained in a letter to Texas HHS from administrative law attorney Jason Ray who forwarded TDMR a copy.
Here are salient portions (the full letter is provided in the article on the webpage):
“Although I notified HHSC of the problem in 2018-2019, there continues to be an unreasonable inability to get new dentists timely credentialed to provide services for Medicaid patients through TMHP and the DMOs. The expedited credentialing initiative that used to be available for dentists appears to have deteriorated into a mess of finger-pointing and bureaucratic excuse-making that has resulted in a systemic regression to near gridlock. Certainly HHSC is aware of TMHP’s current backlog of dental provider TPI applications. I am being told that TPIs are now taking 30-60 days to be issued, and often much longer—and this includes issuing new location TPIs for dentists that are already Medicaid credentialed at group practices that enjoy expedited credentialing for their new providers. All of the DMOs report that they will not begin DMO credentialing a dentist for a new location until a new TPI has been issued by TMHP, even if the dentist is already Medicaid credentialed at another location for the group practice. That creates an exception to expedited credentialing that seems to swallow the purpose of expedited credentialing.
“Here is an example. Suppose a group dental practice in North Houston needs a dentist to cover patients at their South Houston location for a month while the regularly scheduled dentist for the South Houston location recovers from a sudden illness. Stated directly, the North Houston dentist is simply moving across town to treat South Houston patients with the same employer. Although the North Houston dentist is credentialed for the North Houston location, the North Houston dentist must apply for a new location-specific TPI, which usually requires at least 30 days to be issued. Only then will each DMO permit the dentist to begin the credentialing process for the DMO. None of the DMOs issue credentialing approvals that are retroactive to the TPI issuance date, which means that there is an additional 30 to 60 days after the TPI has been issued before the dentist is able to see patients at the South Houston clinic. Thus, it is effectively impossible for a group practice to simply have another dentist cover for the South Houston location for at least 60-90 days. That leaves the scheduled (and emergency, non-scheduled) South Houston patients without a dentist for a long time. When a dentist with full (both TMHP and DMO) credentialing at a group practice location needs to help cover for a sick dentist at another group practice location, it seems unreasonable and unnecessary for the group practice to have to wait 60-90 days before it can provide Medicaid services to its patients.
“My clients and I have been consistently told that TPIs are issued by TMHP to assure that Medicaid dentists meet a higher qualification standard than simply being licensed by the Texas State Board of Dental Examiners. We also understand that issuing a TPI for every location that a provider serves is a utilization and audit tool. However, once a dentist has been TPI’d at one location, every additional TPI issued to the dentist (presumably for a new or additional location) has very little to do with the dentist’s qualifications or fitness to serve Medicaid patients. After all, if TMHP believes that the dentist is currently qualified to serve patients in a North Houston practice, why is there a two month lag in making a decision that the dentist can be TPI’d for a dental practice in South Houston? Likewise, although my clients understand that the DMOs have their own processes and standards for credentialing their providers, it seems burdensome and harassing for DMOs to be allowed/required to demand completely new applications (along with copies of diplomas, dental licenses, etc.), then vet that application for months, for a dentist that is already credentialed in their system and simply is moving to a new or additional location.”
We initially thought the best place to ask about the credentialing process was Texas Health and Human Services — Office of the Medical Director, Medicaid and CHIP Services at HHS.
We inquired there and the response was that they didn’t know anything about credentialing and didn’t know anyone in HHS that oversaw that process.
This is the verbatim response when asked if there was someone we could speak to about credentialing at HHS – “I am sorry. I don’t know of anyone at this point in time. But please look at: Provider Enrollment | TMHP. Maybe you could call that number to contact TMHP… ”
So we called the TMHP Contact Center at 800-925-9126 and spoke to a very efficient and polite provider relations support person.
She said credentialing applications take varying amounts of time to approve depending on the application.
She said under ideal circumstances it should only take a week to get a dentist credentialed for a new location if he is already credentialed at others in the same practice. If things were taking longer, TMHP provider relations support welcomed phone calls to resolve outstanding issues with an application to get it approved.
We then called the agency Texas DMOs and MCOs use as part of the Texas Credentialing Alliance — Verisys. It used to be Aperture Credentialing LLC. but Verisys and Aperture Health merged in 2021.
We gave them a call. We reached an individual involved in the credentialing process for Texas DMOs.
When asked about the process, he said the longest delays came from the DMOs not forwarding the applications in a timely manner. He said their part of the credentialing process was the verification of the applicant’s information and this might take two to three months.
TMHP is no longer including the TPI (Texas Provider Identifier) in their welcome letters introducing newly approved dentists so the DMOs have to wait until the state puts the provider’s TPI in the master provider list to get the number. While practice administrators can get the TPI over the phone, that’s not sufficient for the DMOs. They must have it in writing from the state in the portal or the welcome letter. But TPIs haven’t been available in the portal since it was upgraded either. The result is that it is now taking months for these TPIs to show in the state’s master list for some providers.
Thank you for filing this. This will be a benefit to all of us. Our next priority should be to fight for higher fee’s and fee’s that are similar on like/kind procedures. Like make all the crown fee’s the same. Right now a gold crown pays more (still crappy) than a porcelain crown, so people get gold everywhere. I PFM pays more than a porcelain crown, so on the anterior dentists still cannot do the best aesthetic procedure, because it pays nothing. It is a bad spot. Do a procedure and lose money, or do a lesser procedure. A three or four surface primary restoration should be paid the same as a crown for a pediatric tooth. A 5 surface anterior restoration on a primary tooth should have the same pay as a resin crown. Many of these things are no brainers, but they are left different, so when a new dental director or advisor to a DMO comes on board, they can try and find dentists who are doing the higher cost procedure and accuse them of fraud. There are enough like/kind procedures that they need the same fee, so there is not attempt to attack a dental office, for finding the highest paying procedure for the procedure.
IMO – people simply don’t know what they are doing. I have never experienced severe issues submitting applications through TMHP’s PEMS, nor with the MCOs (with the exception of UHC – which isn’t a credentialing issue – it’s more of a UHC provider customer service issue), unless their was an issue regarding the provider’s license, background check or TSBDE disciplinary action. It was a bumpy road for the first few months of using the new PEMS in early 2022, but those kinks have been worked out. TMHP even offers scheduled walk-through assistance to complete the applications.
It also depends on your entity’s structure. Do you have a type 2 npi? Do you have or plan to have associates? It comes down to a lack of knowledge when it comes to the complete picture, unfortunately.
I do agree with the fight for higher fees.