After our article last month on rate and coverage drops in Webb county for Medicaid waiver patients when DentaQuest took over the program, it didn't take too long for us to be contacted about similar concerns within CHIP and children's Medicaid.
Irate letter received
We received a rather irate letter from a Medicaid dentist who did not wish to be identified to avoid reprisals from the DMOs they are criticizing. But they wanted their views published as a wake-up call to other Medicaid dentists and state representatives that something needs to change so that these insurance companies which profit mightily from their Medicaid contracts get off the necks of individual providers and stop dictating patient care with ridiculous rules to everyone's detriment except their own.
Don't bother asking DMOs for comment
In the recent past, we have not had much luck getting comments from individual DMOs about such accusations when we have reached out. So we don't bother anymore. DentaQuest at one time was quite responsive but that dried up in 2018 when we wrote about their capitation payment program and the concerns over it. Still, we welcome any written response and would publish it accordingly.
Here is the letter:
DentaQuest leading the state and other DMOs to another Frew-type disaster
I writing to you with a sense of urgency and with a plea for help in getting the message to those in charge about the dangerous game that DentaQuest and the other DMO's are playing with the health of some of the most vulnerable children in Texas. DentaQuest is notorious among providers as the DMO that repeatedly displays a lack of knowledge or regard for what our most underserved communities need in terms of dental care. They have made several changes that are clearly motivated by greed, under the guise of having some responsibility to the state to make these changes.
All changes are clearly designed to limit care to the poorest and neediest children in the state without any regard for their duty to help the state protect and look after these children's oral health. These changes coupled with providers who have not seen a fee increase in almost 15 years and an increase of over 50% in costs, the system is being pushed to an invisible limit. DentaQuest and the other DMO's who have followed DentaQuest down this dark road, have created a dangerous tinderbox. The clock is ticking to the next disaster.
The match that will likely light this tinderbox is the so-called "3-year" rule, which bars any office from replacing a failing or broken restoration/filling that was done at the same facility within 36 months. Anyone who has reviewed any literature on the longevity of composite restorations on pediatric teeth knows that approximately 20-25% of restorations fail within 24 months in the general pediatric population. That means 1 in 4 fillings will chip, completely fracture, or have recurrent- marginal decay within the first 24 months. Low-Income children also have a 62% higher rate of decay and are far more likely to have recurrent decay.
The restrictive 3-year rule was first initially instituted by DentaQuest and later adopted by MCNA, and united. It effectively asks dentists who have seen the reimbursements decrease more than 15% over the last 15 years and costs go up more than 50%, to warranty work on patients in a population that is most susceptible to dental decay, vulnerable low-income children on Medicaid.
The DMOs would say that they allow preauthorization for treatment that falls within the 3 years and is necessary. These Pre-authorizations are almost always rejected, OR they are accepted and the fee adjusted to 0$. They are basically slapping the providers in the face by acknowledging that the restoration needs to be replaced, but that it needs to be done free of charge at the dentist's loss in time, staffing, and materials. Maybe the big corporate practices can afford thousands in free work every month, but the little guys like me do not have this option. We are stretched as thin as possible, our practices are about to collapse. We need the DMOs to reduce the 3-year rule and adjust it to 2-years at the most like many other states have such as Florida.
I am sure these restrictions have made the DMOs a lot of money, and they would claim that they are saving the State of Texas a lot of money as well. But they have wreaked havoc on the Medicaid patients and the dentists serving them. HHSC will become COMPLICIT in the inevitable tragedy that will occur as they are allowing the DMOs to sacrifice the health of the most vulnerable among us.
If you check the statistics, I bet you would find that emergency dental visits to the ER have increased since the institution of this 3-year rule. This time bomb is ticking, those in State Government need to get their heads out of the sand, this time they cannot claim ignorance and the penalty for what happens needs to be severe for the DMOs.
A Concerned Dentist