Controversy over DMO Not Paying for Work on Same Tooth

MCNA's headquarters in Ft. Lauderdale, Florida

Back in February, MCNA issued a Provider Bulletin that effective March 15 it would start reviewing restorations being redone within 36 months. The company would also start requiring prior authorizations for identical restorations and similar restorations on the same tooth.

Prior authorizations needed with evidence for work on same tooth

According to the bulletin (available below), for similar restorations on the same tooth, the prior authorization requests must include “a narrative explaining the rationale for the rework and supporting radiographs and/or photographs.”

Report of prior authorization requests denied

TDMR recently received a report alleging that MCNA, despite receiving all information including radiographs showing new decay on a tooth, has denied such pre-authorization requests. It is further alleged in the report that prior authorization requests for replacement fillings have also been denied no matter the reason and evidence presented and that the dentists involved are being told that they are responsible for fixing the fillings for free.

We note that we haven’t received original documents to verify these claims and do not know how many providers have been involved.  But we believe it is important to bring this matter to light.

Response from MCNA

TDMR emailed MCNA executive vice-president Shannon Boggs-Turner asking about this policy and she kindly responded.

“MCNA is clinically reviewing repeat restorations. Providers must submit additional information to enable a review of the service. Both plans have taken a similar approach to deal with what is a serious clinical concern. As you know, restorations, when done properly, are anticipated to last a reasonable amount of time. MCNA is not “refusing to pay for any new or replacement fillings,” we are simply requiring submission of clinical information to enable our Texas-licensed dentists to evaluate the restoration.”

We have subsequently responded that “One can understand the policy if it is a replacement of the same filling. However, we were told that even with supplying radiographic evidence of new decay on a tooth, prior authorization requests are being denied and the MCNA rep is saying it is up to the dentist to do the work at no cost.”

Not sure how large a problem 

We do not know how general a problem this is or if it is only a few isolated instances or if it occurs with DentaQuest as well.

TDMR is open to receiving information from more providers on this issue as well as comments from the DMOs.


5 Responses

  • I completely agree how ridiculous it is for MCNA to constantly dent redo fillings. It is unfair to the dentists to constantly do free work when it is the patient’s lack of hygiene care at home that cause the restorations to have recurrent decay!!! If this policy continues, patients will not be happy if they have to pay for the restorations out of their pocket. This will eventually make dentists not accept Medicaid and will then lead to more unhealthy dental patients. I believe one year is reasonable to have dentists redo their restorations but 36 months is completely ridiculous!

  • MCNA and DentaQuest are definitely refusing to pay for any new or replacement fillings that are less than 3 years old. They are pretty sneaky about it too. In the pre-authorization form, the tooth that sent in for pre-authorization would state “approved”. There’s a catch, next to the word “approved”, there’s a code 821. You would then have go to the 2nd page and read the explanation for the code “This procedure is medically necessary, but the original provider, facility, or group is responsible for the replacement”. MCNA and DentaQuest are not taking into account of many factors for a resin restoration failures…uncooperative patient causing compromised isolation, poor oral hygiene, patients’ occlusion.
    Why is MCNA and DentaQuest requiring prior authorization for a tooth that had an occlusal decay restored less than 36 months and the same tooth have a new Buccal or distal decay?

  • Placement of restoration on the same tooth after two years of original placement was not paid by MCNA , even though all the documentation was provided indicating presence of recurrent decay and they have denied to pay for the restoration repeatedly

  • We recently received our December remittance from MCNA with a large amount of money recouped due to the Standard of Care effective 03/2019. The problem is that the procedures they are recouping are previous sealants and stainless steel crowns. So for example, we did a sealant in 2016 and a filling in 2018, they recouped the sealant. All of this prior to the effective date of the Standard of Care and the procedure codes they listed, did not include sealants or stainless steel crowns. So any doctors out there willing to concur that sealants and stainless steel crowns are identical or similar to a filling? We contacted our reps and were told that they will be recouping the money and if we want we can appeal the claim. We numerous offices and for one remittance for those offices it is well over 8000.00 with more to come. How can they recoup any monies prior to the effective date of said policy?

  • I do not agree with their action of recouping paid claims for ceilings that were done to three years ago, I don’t know under what authority they think that they have a right to do whatever they like to do , I do not think they can do that and they need to be stopped

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