Remember we wrote that Texas should beware of DentaQuest and its corporate behavior, which cost the company $11 million in fines in Louisiana for Medicaid contract violations, which was recently cited in a report by the Louisiana Legislative Auditor’s office.
DentaQuest’s recent history has been poor
The report noted that “Providers noted continued issues with denials of claims. Some providers reported that the denials are inconsistent with current clinical best practices and guidelines and are the opposite of what is being taught in dental school residency programs. One provider stated, “Perception is that they are looking for ways to save money so they can show the state that they are saving, but they are denying medically necessary and needed care.”
TDMR also reported that Massachusetts gave DentaQuest the boot this year after its long-standing contract as the state’s third-party payer ran out, and it replaced the company with Benecare. Complaints were legion from numerous state dental groups, including allegations of medical discrimination, access to care violations and quality control failures.
Financial troubles affect parent company, vows change
This shabby performance has impacted its bottom line and upset its Canadian parent company, Sunlife, with its CEO vowing changes.
In May, Reuters reported that Sunlife had its first profit miss in 12 quarters due to a 20% drop in DentaQuest’s earnings in the first quarter of 2024.
Importantly for Texas Medicaid providers, Sunlife CEO Kevin Strain had the following to say:
“Medicaid enrollments in Sun Life’s U.S. dental insurance program have declined after the end of the COVID public health emergency last year and costs from the remaining members have increased. Strain said the company is now negotiating for higher payments from states, with about 25% of its Medicaid business already repriced close to the company’s pricing targets and the remaining expected to be repriced by the end of the year. [emphasis TDMR]”
Changes in Texas
Rumor has it that there has been a shake-up at DentaQuest offices in Texas and Texas is apparently at the receiving end of one of these “pricing targets.”
Surprise! DentaQuest stops paying for two surface fillings
Since June, DentaQuest has been telling Medicaid dentists in Texas that it will now only pay the one surface rate for two surface fillings that aren’t interproximal, claiming this is an industry-standard.
One provider told TDMR, “DentaQuest has been downgrading two-surface fillings and paying the price of one. They are only paying for two surfaces if they are interproximal. When we asked for data supporting this practice—since no other insurance does this—they claimed it was ‘industry standard.’ This is the first time any of us have heard about anything like this.”
A dentist told TDMR, “The reasoning that they have come up for this has continuously changed over the last few weeks. Their first explanation was that OL and OBs are not considered Class 2’s like MO and DO restorations, so they will be paid as Class I. This explanation was particularly disturbing because it was shockingly uninformed. A company this big couldn’t figure out that “Class 1” and “Class 2” are part of GV Blacks classification and have nothing to do with billing codes. Dental billing codes have always been based on the number of surfaces a restoration touches. GV Black classification does not apply…After that, they adjusted their explanations, basically saying that OL and OB’s are not time-consuming and therefore they are only going to pay them as one surface. Again, an absolutely asinine explanation that makes their “down coding” seem like nothing more than stealing in plain sight.”
DentaQuest as a DMO gets paid by Texas on a Per Member, Per Month basis. So, this is a clear cost-cutting measure on the backs of Medicaid providers to help their parent company reach their profit targets. Who said Canadians were nice?
More bad news for dental providers
As Texas providers continue to get hammered by the dental staffing crisis and inflated supply prices, this is just another nail in the coffin for dental Medicaid in the state.
As one provider commented to TDMR on their struggle to keep afloat, “We are struggling to keep our staff. Our staffing costs are substantially higher than the upper range of the estimates in the article. Our lease is expiring soon. We are considering moving to a more affluent area of town and no longer accepting Medicaid, selling, or just closing down.”
And another, “We are a provider of Medicaid children’s dental in TX and we are having an extraordinary time keeping up with Medicaid reimbursements vs the cost of running and staffing a dental office – Unless TX raises fees and keeps up with inflation – kids on Medicaid in the state of Texas will suffer since they will NOT find providers readily available to treatment these high risk patient population.”
How will Texas HHS respond?
We have been told that a number of providers have complained to Texas Health and Human Services about this DentaQuest pricing maneuver. Some are even reaching out to CMS at the federal level.
As far as we know, there has not yet been a response. We certainly hope it is in the favor of providers, not a large insurance company trying to please its parent company or make its profit targets.
Oh, yes, will a dental fee increase be forthcoming? This is the big question for Medicaid dental providers too.
What is interesting is the impotence of the state and HHSC to correct an issue that is basically fraud against the providers by an entity that supposedly works for them. Legal action by the providers or intervention by federal overseers is probably going to be the result of all this.
As a Medicaid provider in Texas, I’m outraged by DentaQuest’s blatant disregard for our profession and the patients we serve. The recent decision to downgrade reimbursements for two-surface fillings is nothing short of theft dressed up as “industry standards.” This is not just a cost-cutting measure; it’s a direct attack on our ability to provide essential care to Medicaid patients. We are already struggling with staffing shortages and rising costs, and now we have to contend with a company that seems more focused on profits for its Canadian parent than on the health of our children.
It’s infuriating that DentaQuest continues to deny medically necessary treatments while claiming they are saving the state money. This is a reckless approach that will ultimately harm our most vulnerable patients. I’ve heard from countless colleagues who are considering leaving Medicaid altogether, and honestly, who can blame them? If Texas Health and Human Services doesn’t step up and protect providers from this corporate greed, we will see even more dental offices close their doors, leaving kids without the care they desperately need. Enough is enough!
Our dental clinic has been facing significant financial challenges due to DentaQuest’s illegal practices of downgrading payments for services rendered to Medicaid patients. Despite providing essential care, we have not received adequate compensation, which has been further exacerbated by rising inflation and their consistently low payouts. It is very sad that DentaQuest has forced our hand to make this difficult decision, but we are left with no choice but to drop them from our accepted insurance plans, as we can no longer afford to keep our doors open under these unsustainable conditions. Maybe the states need to come up with their own MCO’s and not let a Canadian parent company dictate payment to healthcare providers. If this continues and more providers drop Dentaquest or other MCO’s like we are doing I can see another 2007 incident happening again when the states will beg providers to take Medicaid plans again, then it might be too late. State officials need to monitor this situation before things get out of hand.
Their entire rationale of “degree of difficulty and fewer materials used” is complete hogwash and they are not fooling anyone. If they gave a damn about that, they would be paying for pulp caps among other things. This stinks and we are allowing the rot to continue. I desperately hope that the TDA/TAPD and HHSC do something about this. It would bring me no greater joy to drop them but unfortunately, my practice is about 50% medicaid and I am feeling despondent about the situation.