The policy revision to the Medicaid orthodontic benefit process contemplated by representatives of the Texas Medicaid and Healthcare Partnership and the Health and Human Services Commission in 2009 was sweeping. Per the final draft of the confidential policy revision attached as an exhibit to a court filing by Xerox last month, it would have eliminated and replaced billing codes, created new levels of orthodontic difficulty to be treated, changed the necessary submissions to accompany a prior authorization request and restricted the training of who could treat and bill.
HLD score sheet to be eliminated
The new policy would have also eliminated the HLD scoring sheet, that bone of contention upon which former HHSC Office of Inspector General staff Jack Stick and Doug Wilson based their faulty allegations of hundreds of millions of dollars of orthodontic Medicaid fraud.
No changes to Xerox prior authorization process
However, it would not have changed the TMHP/Xerox prior authorization process at all.
In fact, the policy revision ignored the concerns of the dentists involved in the program which was supposed to be a key policy issue to resolve. The policy would not have told dental stakeholders about the process and who did reviewing. The only remark about the process was that “The TMHP Dental Director or designee must review all requests” which, of course, was non-existent at the time for the 8,000 or so prior authorization requests being submitted monthly.
Xerox only checking arithmetic, not medical necessity
It is a rather remarkable thing that a policy and program review of this magnitude would totally miss the “elephant in the room” – that the TMHP/Xerox prior authorization process had done nothing except check the arithmetic skills of dentists rather than check the correctness of the submission for medical necessity. Nothing was being done to change this. TMHP would apparently use the same high school graduate “dental specialists” working from home to review the new submissions. One wonders why the state didn’t question why Xerox was getting paid for this.
Without addressing this issue at all, the new policy agreed upon by HHSC, OIG and TMHP/Xerox reps seems to increase the number of prior authorization requests a dentist might have to submit for one case as it states “Only one orthodontic treatment dentition procedure code will be prior authorized at a time.”
Policy change never implemented
Be that as it may, the policy was never implemented. Texas was left with a sham prior authorization process that led to dentists believing board certified orthodontists were reviewing and approving their submissions.
Below is a PDF file showing the bulletin and website notification that would have been published giving full details about the changes had they been implemented.
Would like to know provider opinions of policy and its potential effects
We would appreciate knowing your thoughts on this policy that was never implemented and preferably facilitate a discussion. Would it have been better? How would it have affected your practice?
Please leave a comment below or email TDMR at firstname.lastname@example.org.Exhibit-F-policy-notify
The full document can be downloaded here.