Dentists Told in 2009 to “Assume” Medicaid Ortho PAs Are Reviewed by Board-Certified Orthodontist

THHSC buildingBack in January 2009, a Medicaid Orthodontic Stakeholder meeting was held in Austin at the offices of the Texas Dental Association.

Dr. Linda Altenhoff presided at the meeting. Dr. Altenhoff is currently the Dental Director for the Texas Health and Human Services Commission Office of Inspector General, a position that was created under SB 1803. Back in 2009, Dr. Altenhoff held the position of State Dental Director, Texas Department of State Health Services.

The purpose of the stakeholder meeting was to introduce to those attending a proposed draft of changes to THSteps orthodontic policy. A copy of the agenda is available here for download.

Medicaid dentists told to “assume” prior authorizations (PA) are done by a board certified orthodontist

The proposed agenda contains a list of assumptions.  On both page 5 and the page after, a key assumption is listed :

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.

All of these changes to policy apparently were driven from provider input that occurred on October 8, 2008, per the agenda document.

Obviously, as far as prior authorizations were concerned, Medicaid dentists and orthodontists were concerned and wanted their requests reviewed by a board certified orthodontist to ensure their applications met the state’s requirements.

Clearly too, they were told that such approval meant the case qualified for Medicaid treatment.

HHSC misleading Medicaid dentists

But, of course, in reality this wasn’t close to happening.

Per the Attorney General’s suit against the “Health and Human Services Commission claims administrator contractor” Xerox, HHSC knew in August of 2008 that Xerox’s “dental specialists” worked from home, did not review medical data and eventually got the admission from Xerox that the only skill required was the ability to add HLD scores. In fact, Xerox dental specialists had worked that way since 2006.

If Dr. Altenhoff didn’t know about the findings of this 2008 HHSC-OIG audit of Xerox and their Medicaid orthodontic prior authorizations process and its deficiencies, why didn’t she?

HHSC knew for four months (audit issued August 29, 2008) the truth about Xerox/ACS dental specialists before this meeting.

If she did know, why did she tell Medicaid dentists a fallacy?

Fraud?

Texas dentists and orthodontists were told by an HHSC dental director at the offices of the Texas Dental Association that they should assume all their Medicaid orthodontic prior authorizations were being reviewed by a board certified orthodontist .

That’s pretty powerful authority to use to misrepresent what was actually occurring.  Did HHSC intentionally deceive Medicaid dentists?

Per SB 1803, “fraud” means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or some other person, including any act that constitutes fraud under applicable federal or state law.

There needs to be an investigation.

 

One Response

  • The potential fraud you’re describing has huge financial implications for the State of Texas, which spent $1.1 billion over the last decade on orthodontic insurance claims. Keep up the coverage of this issue, thanks.

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