The TMHP document reported about in our last story that was recently appended to a court filing by Xerox shows that staff from the Health and Human Services Commission and its Office of Inspector General were well aware of the details of Xerox’s orthodontic prior authorization process. They knew because TMHP/Xerox did answer the five questions asked by Medicaid dentists about the process in 2007 although the dentists never got them.
State lawsuit holds prior authorization process misrepresented
The Office of Attorney General, on behalf of Texas, filed suit against Xerox in May of 2014 at the same time the company was terminated as its Medicaid claims administrator. The lawsuit alleges that the company’s prior authorization process for Medicaid orthodontic treatment was fraudulent because Xerox misrepresented its process to Health and Human Services Commission officials. Xerox was supposed to be obligated to have such requests reviewed by trained dental staff. Xerox has stated that HHSC knew and approved everything.
Document shows process represented accurately in 2009
While the qualifications, piece-work and working from home details were not included, TMHP/Xerox looks to have been pretty upfront about how the prior authorizations were approved. They told HHSC if the HLD score was 26 or more (the addition was checked) and x-rays submitted, a prior authorization request was automatically approved.
Here are those answers:
l. Who is involved in the review of orthodontic cases?
TMHP dental specialists review the information the provider submits. If the client has an HLD score of 26 or greater (measuring the dysfunctional malocclusion), and the provider submits the X-rays with the request, the request is authorized. If an HLD score of less than 26 is documented the request is denied. Except when the dental provider puts a note on the request about the medical need for orthodontia even though they do not have an HLD score of 26, then the request is referred to the TMHP Dental Director for review.
2. What are the criteria for the review of orthodontic cases?
If the client has a request submitted by a licensed general dentist, pediatric dentist or an orthodontist and the provider has submitted x-rays and the HLD scoring sheet with a result of 26 or greater, the specialists approve the request as per policy. If the x-rays are not submitted or the score is below 26, they deny the service. Except when there is narrative submitted along with the x-rays and the HLD score sheet with a result below Z6, the request is reviewed by the TMHP Dental Director. The guidelines in the medical policy must be met for the specialists to approve the orthodontia.
3. What is the process when a difficult orthodontic case is presented?
Any request that does not clearly meet guidelines but the provider submits information regarding why this should still be considered for approval (even though the guidelines are not met are reviewed by the TMHP Dental Director.
4. What is the level of understanding of orthodontics by the providers who present orthodontic cases?
According to the state law, any provider that is licensed by the State of Texas to practice dentistry can do orthodontics, This would include a general dentist, pediatric dentist, or an orthodontist.
5. What type of interceptive orthodontics is available for children in the age range of 6 to 7 years?
Currently, we authorize for treatment to correct an anterior or posterior crossbite.
So while HHSC was told, providers never were. They were told to expect that a board certified orthodontist reviewed each case!
The excerpted pages from the document shown below give the names of the staff from HHSC, TMHP, and OIG that were developing the new orthodontic policy along with the answers.
No issues of fraud, waste and abuse
Perhaps more importantly, the document indicates that fraud, waste and abuse by providers WERE NOT ISSUES considered in the policy revamp. This is despite the fact that in 2008, an OIG audit found that there was potential for fraud in the system. Certainly Xerox and its prior authorization process weren’t suspect!
Considering that HHSC staff had these details, the state’s allegations against Xerox appear weak.
Discussion about review by board-certified orthodontist
There was a discussion in the document about changing the review process so it was done by a board certified orthodontist but that is our next story.
The full document can be downloaded here.Exhibit-F-excerpt-2