I am in support of Bill 1536 to allow dental providers to have formal hearings by the State Office of Administrative Hearings (SOAH) rather than by the HHSC.
I would also like to suggest that the bill include provisions to protect the providers at the start of any investigation by the Office of the Inspector General (OIG) and at the time of any payment withhold. In addition, requiring hearings to be done in a timely manner should be implemented for any investigative process.
I have been the professional association (PA) holder and dental director for Trueblood Dental Associates, affiliated with Carousel Pedatrics since 2008. Carousel Dental treats nearly all Medicaid and primarily Hispanic children. Trueblood Dental Associates (TDA) was placed under investigation by the OIG last fall. This investigation into TDA is possibly due to several factors. We are a large provider group and generate a large revenue due to the amount of patients we provide care to, thereby making us a target for investigation without merit.
Van Dyke PA is also affiliated with Carousel manangement company and they were originally placed under OIG investigation for orthodontics. TDA has no interest in the VanDyke PA and is completely a separate entity although we did use the same management company.
After the ortho investigation, Carousel Pediatrics was placed under investigation. Again, separate PA. The owner of Carousel has been very vocal in defending his position on patient care and I fear that in retaliation, Carousel Dental/ Trueblood Dental Associates was targeted as well.
Trueblood Dental Associates delivered 88 charts as requested in the 72 hours allotted upon receiving notice of the audit. I understand the need for the OIG to obtain information quickly in order to proceed with their investigations and to prevent the possible creation of fraudulent documentation, etc. However, we were not able to get some of our information in the time frame given. For instance, the informed consents for our patients that were treated in the hospital are stored in the charts at the facility where they were treated and we could not obtain those in time. We also have several clinics which made finding all the information a challenge.
We continued to gather information and requested to submit that information as soon as we obtained it but were denied. Many of the charges brought against us were lack of informed consents for this reason, so it is important that there is a process by which additional information can be submitted.
The OIG suddenly and without notice placed a 100% hold on TDA/Carousel in February. We immediately requested a hearing and at least a reduction on the withhold so we could continue to operate and provide care for our approximately 22,000 patients. Many patients were booked several months in advance for routine visits, sedations and hospital visits for children with more extensive treatment needs.
We were denied a reduction in the withhold and yet we were never given any sort of dollar amount that the OIG accused us of overpayment. Because of this, we were forced to close 3 Carousel locations. Four dentists and 30 staff lost their jobs without warning. The patients were forced to try to find other providers and 22,000 patients were in jeopardy to making access to care more difficult.
We have requested a hearing and it is scheduled for May 7. In the meantime, we are prevented from providing care and most likely will not be able to recoup our losses and recover.
I have looked at the charges against our provider group and many of them were completely erroneous.
Carousel and Trueblood Dental Associates have never solicited patients in any form. The informed consents as I mentioned earlier. Failure to take weight and blood pressures on small children was mentioned. This charge is not against any guidelines. In fact, the HHSC guidelines state that only children over the age of 12 require vital signs to be documented for routine visits. As you may imagine, it can be difficult or impossible to obtain this information on a 2 or 3 year old for a routine exam and cleaning and is not required. Similarly, a weight is not required unless there is a concern about the maximum dose of local anesthetic that can be used or for medications during sedation procedures.
Carousel had the 88 charts that we submitted for review to the OIG examined independently by a dentist who was a previous reviewer for the state board. This dentist found that our treatment and documentation and billing to be overall correct and acceptable for our patients. The OIG, in order to conduct a fair, balanced, and thorough investigation, should require that charts are reviewed by several board certified pediatric dentists who also have experience in treating the Medicaid population, as there are differences in the approach to care vs. the private sector, due to their risk factors for decay. I myself am a Diplomate of the American board of Pediatric Dentistry and have had extensive training and experience in providing education and preventive care as well as treatment to the lower socioeconomic sector.
Simply because we are a large provider group does not mean we are committing fraud. Our percentage of patients requiring full mouth dental rehabilitation involving a significant number of teeth that require treatment has dropped drastically in the past 5 years. I have performed all the treatment for children requiring care under general anesthesia for all of our locations and the number of patients as well as the number of teeth per patient needing restoration is dropping due to our focus on educating parents about risk factors such as diet and oral hygiene. We are also catching caries earlier by seeing these patients at an early age and for routine visits.
Only about 8% of our patients require extensive dental treatment. Considering that 5-10 % of the overall population of preschool children suffers from baby bottle decay and according to Head Start, 30% of children in metro areas from lower income families suffer from dental decay, our efforts appear to be positively affecting our patients. We are working hard to continue to provide care but have been prevented from doing so due to prejudice against us for being a large provider group, and without due process.
As a taxpayer and a dentist who takes my job to provide excellent care for my patients very seriously, I am in favor of prosecuting providers who are abusing the taxpayer system. However, there needs to be a better system for divining this information without putting providers out of business based on assumptions and patients losing access to care due to lack of due process. Bill 1536 will help to ensure that a providers constitutional rights are upheld and that the process can be expedited for the benefit of all.