DentaQuest-led 3-Year Rule Outrages Medicaid Dentists

TDMR published a letter from a dentist a month ago who expressed their outrage about DMO self-made rules that restrict and inhibit treatment of young Medicaid-eligible children to their detriment. Now that the holiday season is well out of the way we want to bring this issue again to the forefront.

Pretty mad

The doctor's ire was particularly directed at the "3-year rule" initiated by DentaQuest but adopted by MCNA/United Healthcare Dental (same company really). This rule forbids dental practices from getting paid for replacing a failing or broken restoration/filling in a child that was done at the same office within the last 36 months. Such failures are not unusual for children in low-income families due to a higher rate of tooth decay and the failure rate of such restorations.

Because the DMOs won't pay, the onus falls on the dentist or practice to cover the cost and provide free service to maintain the standard of care for the patient. The DMOs unbelievably continue to get paid their capitation rate for the patient by the state despite this premeditated lapse in their care.

Lots of comments

Rarely does a TDMR story evoke 25 comments. So we thought we would republish a selection of them here to highlight the outrage felt in the Medicaid dental community about this rule.

"I have been saying this all along! Instituting the 3-year rule is a clear example of patient neglect. There will be so many children in underserved communities that will suffer the consequences because of it."

"The 3 year rule is not based in any science or rationale, it’s a made up arbitrary timeline that hurts those most in need. Kids with high caries rate are susceptible to recurrent decay, we should be able to treat their disease. Some states like CA have a one year rule."

"We’ll said! One other issue with this 3 year rule and the pre-auth requirements is that that it makes same day treatment impossible. From my experience, these patients have a notoriously high no-show rate and it is hard enough to get them to the office for their periodic exams let alone an additional visit if/when pre-auths are approved. By and large the patients are the ones that suffer and smaller issues turn into much larger problems. Please reconsider this 3 year rule as it is not fair to the patient nor the providers."

"This is absolutely correct. As we are a high volume Medicaid office, a one owner parctice) with multiple providers, we also have felt the impact of not being able to give one day service to patients who already struggle with transportation, relative guardianship, and multiple other issues that hinder treatment."

"I concur 100% with the criticisms of the 3 yr rule. A similarly ridiculous and onerous new practice is requiring labeling and attachment to claim of all radiographs, and then they are reviewed and payment denied. The additional time required to label and attach is not cost effective by any means. It follows the orthodontic criteria model established in 2011, since then not a single qualifying case has been observed in my practice, and if it did, I could not provide orthodontic treatment with the new fees."

"Well said !! Especially the part about operating under the guise that this helps the state. The only people who win are the insurance companies and that’s it. The state will still be on the hook for the bigger more expensive treatments that will result from ignoring decay for 3 years! And for those patients that lose their coverage, well they’ll eventually end up at the local ER. As a practitioner, we get letters every year around this time encouraging us to buy more supplies because (surprise surprise)prices go up in January, again. There will come a time very soon that this no longer makes sense for anyone, and the people who suffer the most are the most vulnerable. Greed will always lead to downfall"

"Agree with the doctor’s letter. The three year rule and lack of proper pre authorization from DMOs has been a detriment to patient care and doesn’t take to account the statistics this doctor wrote about with very vulnerable portion of the population having more recurrent decay, lack of proper oral hygiene. With the increase in costs of materials and labor, and no increase in fees, with these restrictive rules which don’t follow the statistics. Us dentists will struggle across the board, which leads to the question who is really benefitting? The patient isn’t. The dentist isn’t. It’s just the DMOs and THAT needs to be looked into."

"When evaluating healthcare policies the biggest variable to take into consideration when making decisions on guidelines and reimbursement should always be the health of the patient. We all understand that underlying our endeavours, be it the doctors, the state and the insurance companies, are the financial gears that allow all of three players to continue functioning. So yes, we all understand, it is a business, but not at the cost of the patients’ health and the provision of timely treatment. When DMOs enact a rule, such as the three year rule, the patient’s health should be at the forefront, and I find it very difficult to find any evidence based literature that supports such a timeline. So then, when trying to understand the reason behind this three year enactment we are left with nothing more than a financially-driven decision sprouting from within the boardroom discussions at Dentaquest. When restorations fail after a year or two, us doctors are left with the moral pressure to treat or not to treat, at no charge, while Dentaquest turns a blind eye to the responsibility of providing care to patients, which is their job! If these patients go untreated while they wait for the three years to pass and consequences arise, it is the shoulders of the State and the doctors that bear the burden of liability, while the DMOs wipe their hands clean. The State took a large legal and financial loss 15 years ago for this very same issue, young children seeking timely care but not finding it due to reimbursement limitations. The State will carry the heft of the weight of any consequences arising from untreated children because of restrictions that bind the hands of us doctors. It is high time that DMOs loosen restrictions that are not founded on scientific evidence, restrictions that they enact based solely on financial considerations, and allow the doctors to do their job with the health of the children at the forefront of everyone’s priority list. It is time that Dentaquest reduces the 3 year rule, to allow us doctors to do our job in taking care of our young patients with their health and safety in mind with scientific and evidentiary foundations, while not forgetting the financial machinations that allow us all to continue providing that care. We can all be moral and ethical, and still function as a business together. Reimbursement decisions not grounded on medical evidence, and solely founded on financial reasons should be stopped. Reduce the 3 year rule immediately!"

"The 3 year rule is outrageous and illogical. It’s hurting the large community of children in low income families and the small dental offices serving them. The DMOs need to rethink this rule which only serves them and not the greater good. Texas Gov. needs to step in and change this rule."

"These DMOs are a complete joke. The 3 year rule has destroyed our offices. Every year our costs keep going up and the reimbursement fees keep going down."

"There is some support for the concept of a class-action legal action against DentaQuest and MCNA on behalf of the patients they are claiming to serve. This is a different level of callousness and greed, and it will come back to bite them hard. When it does, the repercussions need to be severe."

These healthcare professionals sound pretty upset.

One Response

  • What the UHC is essentially saying is “leave the poor alone. It is too much of OUR money being spent on them”

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