Some of the evidence that the state is using to pursue Medicaid fraud allegations against its former Medicaid claims administrator on its orthodontic prior authorization program from 2004 to 2012 comes directly from depositions of the Xerox/Conduent dental director, Dr. Jerry Felkner.
Xerox/Conduent kept telling the state in their policy manuals that he was reviewing cases when in fact he wasn't.
Xerox PA manuals included dental director review
The company's 2004 Dental Authorization Department Policy and Procedures Manual given to HHSC states for the ortho PA [excerpted]:
- After the request is checked for eligibility and duplications, the Dental staff will unwrap the corresponding dental molds and prepare them for display.
- The Dental Director will review the request online, and review the necessary molds, x-rays and images pictures.
- The Dental Director will place the decision in the comment screen of the client's Phoenix authorization screen.
- When the authorization process is complete, the Dental staff will re-box the molds and secure for mailing.
In March 2009, Xerox had revised its P&P to state [excerpted]:
- All PA requests, including documentation or information received on the phone, must be reviewed for completeness and medical necessity. The TMHP nurse or specialist will determine if the request is a complete request, a duplicate or incomplete".
- Requests are processed to ensure that all eligibility, medical policy criteria, and benefit limitations are reviewed and enforced.
- A 'complete' request has all the necessary information included to make a proper determination on the request at that time. After reviewing all of the documentation and information, the services are approved, modified, or denied using appropriate reference materials...and approved medical policy.
- Once the Prior authorization determination is made, the provider is informed of TMHP's determination by letter...
Forced inclusion in 2009
But then-Texas Medicaid Director Billy Millwee apparently questioned the lack of dental director review in an email to the company representative Eric Holt.
So in April, Xerox/Conduent responded to include:
"The Medical Director reviews the request and determines the appropriate processing of that request..."
But he never did.
Less than 10% went to dental director
Per the court document TDMR has, the state says "Xerox has admitted that instead, 10% or fewer of PA requests went to the Dental Director; the remaining 90% or greater of PA requests went to the Dental Clerks for review. Xerox has admitted there is no language in the P&P statements above that notified HHSC that for the overwhelming majority of dental prior authorization requests the Dental Clerks, not the Dental Director, were reviewing the requests."
Approved them all
Further, "Xerox's Dental Director from 2004 to August 2011, Dr. Jerry Felkner, has admitted that both he and the Dental Clerks did not actually perform a prior authorization of the ortho PA requests but rather, simply approved nearly all the requests regardless of whether the requests met the Medicaid policy criteria or not."
Felkner, in depositions, said
Q. Is it a true statement to say that you approved nearly everything that you reviewed regardless of whether it met Medicaid guidelines for medical necessity?
Q. Is it a true statement to say that if the HLD score sheet was. filled out and the supporting materials were there and the eligibility of the recipient was confirmed the application would be approved regardless of medical necessity?
. For me or for the clerks?
Q. For you.
Q. And can you comment also about the clerks based on what you know?
A. Well, the clerks, again, were looking at the arithmetic. If the arithmetic added up they approved it.
Q. So there really wasn't any determination of medical necessity going on in terms of evaluating the underlying data, correct?
Q. Is that correct?
A. That's correct.
Further Felkner said of those applications he looked at personally that he just approved all of them regardless of HLD scoring or age of the patient.
Q. Did you ever come to have an understanding that applications with HLD scores of less than 26 might still
meet medical necessity criteria under Medicaid?
A. Well, technically they could have a malocclusion; however, I approved all of them regardless.
Q. And when you say you approved all of them, tell us what you mean.
A. The applications that came in, even if they were under 26 I approved them; even if they were under age 12 I approved them.
Q. All right. And did you do that from the beginning of your tenure throughout the time that you left in 2011?
Q. Did that process that you just described of approving all applications regardless of the score and regardless of the age, did that ever change?
A. No, sir.
Q. You understood it was the responsibility of ACS to review the underlying data included with the orthodontic prior authorization applications to confirm medical necessity, correct?
No criminal investigation of company or staff?
Considering that the state knew about the flawed process in 2008, one has to wonder why Texas dental providers were ever targeted at all by the state and why there was no criminal investigation into the conduct of Xerox/Conduent executives and staff that apparently manipulated Texas Medicaid.
The excerpts of Felkner's testimony are below: