Lawsuit Alleges Xerox Wrote Misleading Documents on Ortho Prior Authorizations

justice for texas medicaid providers

As part of the lawsuit against Xerox, the former lead contractor for the Texas Medicaid and Healthcare Partnership, the Texas Office of the Attorney General alleges that Xerox, from the beginning of its contract with Texas, wrote misleading documents that indicated each request for Medicaid orthodontic treatment was submitted to and reviewed by its dental director when this was not the case.

Hide no case review done by Xerox’s dental director

The purpose of the subterfuge per the legal documents was to misrepresent and apparently hide the fact that the vast majority of Medicaid orthodontic prior authorization requests never were sent to the dental director but were “rubber stamped” by Xerox’s “dental specialists.”  These staff, according to the suit, were unqualified, never reviewed the medical documentation, started working from home in 2006 and only added up the HLD scores, ensuring the total was 26 or greater. This practice was initially hidden from the state, totally unknown to dental Medicaid providers and in violation of Xerox’s contract, leading to $1.1 billion in Medicaid spending on orthodontia from 2004 to 2011.

HHSC knew in 2008

Although the state became aware of the practice in 2008 because of a performance audit conducted by HHSC-OIG, no effective action was taken for three years until Xerox was compelled to hire more dental staff in 2011 shortly before managed care was brought in for Medicaid dental.

The lawsuit states:

Xerox assumed operations under the 2003 contract on or about January 1. 2004. At or around that same time, Xerox implemented a different procedure than that described in the P&Ps [policy and procedures]. Without submitting documentation of this change to HHSC, Xerox instructed its dental clerical personnel to automatically approve applications for Medicaid-eligible children, age 12 or over, accompanied by an HLD score sheet that showed a score of 26 or above on its face. The employees assigned to this task had no qualifications to conduct a medical necessity evaluation; and, indeed, these employees made no attempt to do so. In most instances, the employees did not even ascertain that any or all of the required medical documentation was actually submitted by the provider as required by Medicaid policy. Further, the clerical personnel were inadequately trained to review the HLD sheet for obvious over-scoring. If the application was for a person who met Medicaid eligibility requirements and the HLD score was facially 26 or more, approval was entered by the clerical personnel without further examination. This new procedure drastically reduced the number of applications receiving review by the dental director, who was the only person employed by Xerox with the medical qualifications necessary to make a proper review of these applications…

During the course of the 2003 contract, Xerox continued to promulgate written documents indicating that every dental PA request was submitted tor dental director review. These documents misrepresented material facts regarding the actual procedures followed by Xerox employees.

Investigation needed

A state agency which allows its primary contractor to bamboozle them for seven years, spending $1.1 billion in the process without effective oversight or control of the company, should be investigated along with the staff responsible.  Why did this occur?  Who allowed it and why?



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