In the same Xerox/Conduent court filing from July 2018 mentioned in our previous article, there is another exhibit worth mentioning. It is the complete email chain involving HHSC OIG officials discussing OIG investigator Ray Acuña’s meeting notes on the Xerox/Conduent ortho prior authorization (PA) process.
Stopped requiring molds for PA
Some of the correspondence revolves around the fact that Xerox/Conduent had stopped requiring providers to submit molds when sending in their prior authorization requests.
“Altenhoff could shed some light…”
Brian Klozik, the director of the HHSC OIG Medicaid Integrity unit, says in one email:
… I remember Sharon Thompson [former Director of Medicaid Program Integrity for OIG] and I discussed the fact that TMHP wanted to do away with the requirement to have dental providers submit models for PA on ortho. If I recall, there was an issue with TMHP repacking these models and sending them back to the provider. It was creating a burden on TMHP and the theory was the models were not the defining criteria as to whether a child met the required HDL [sic] to gain PA. I seem to remember that Sharon and I were against this but Sharon has just moved into her new position at OIG and I had just taken on the Manager role in MPI …It could very well be that OIG (maybe even me) O.K. ‘d the request to not have providers submit the models, but maintain them for retrospective review. I do not recall any request to have provider stop submitting the radiographs and tracing [this was not true] which, in my opinion, is critical in supporting the 26 points claimed on the HDL [sic] sheet completed by providers when requesting PA.
I could not locate any historical e-mails related to this matter, so this is all from memory and it’s speculation at best. I would think Dr. Altenhoff could shed some light on this as I’m sure she was heavily involved in any decision on dental policy at that time. There must be some basis for TMHP completely abandoning a process that was in place so long with NHIC, and one that I felt worked very well.
My recommendation would be that Medicaid goes back to requiring these elements to ensure proper PA is being given in ortho cases.
Acuña corrects Klozik that only the molds were dropped:
I mis-spoke when I said that Cephalometric x-rays and tracings are not required to be sent to TMHP by providers. Cephs and tracings are still required, however, Dr. Altenhoff suggested that TMHP is not using them to make the PA determination, she suggested that only the HLD scoring sheet is reviewed by TMHP to see if the 26 point requirement is met. Dr. Altenhoff and the stakeholders suggest that qualified dental staff at TMHP be required to review all information required and submitted by providers to make the PA authorization.
This exchange seems to indicate that dental stakeholders know about the flawed process from Altenhoff which they apparently did not. Regardless, it appears that dental stakeholders wanted a valid and meaningful PA process.
“I guess no one really cares”
Thanks for clarifying that Ray I believe that gets to the real issue here .no one is reviewing the x-rays and tracing and TMHP needs a qualified dentist to make these determinations. If I was a provider paying shipping and handling to send in x-rays and realized no one was reviewing the documentation, I would be upset and question as to why this is necessary. Then again….since it appears no PA request is denied, I guess no one really cares.
How true! The process carried on another almost four years without anything being done.
A downloadble PDF of the email exchange is below.Exhibit G Xerox searchable