Medicaid Dentist says DMO Rule Changes Cripple Patient Care and Hurt Providers

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



26 Responses

  • I have been saying this all along! Instituting the 3-year rule is a clear example of Patient neglect. There will be so many children in underserved communities that will suffer the consequences because of it.

  • I concur 100% with the criticisms of the 3 yr rule. A similarly ridiculous and onerous new practice is requiring labeling and attachment to claim of all radiographs , and then they are reviewed and payment denied. The additional time required to label and attach is not cost effective by any means. It follows the orthodontic criteria model established in 2011, since then not a single qualifying case has been observed in my practice, and if it did, I could not provide orthodontic treatment with the new fees.

  • The 3 year rule is not based in any science or rationale, it’s a made up arbitrary timeline that hurts those most in need. Kids with high Caries rate are susceptible to recurrent decay, we should be able to treat their disease. Some states like CA have a one year rule.

    • We’ll said! One other issue with this 3 year rule and the pre-auth requirements is that that it makes same day treatment impossible. From my experience, these patients have a notoriously high no-show rate and it is hard enough to get them to the office for their periodic exams let alone an additional visit if/when pre-auths are approved. By and large the patients are the ones that suffer and smaller issues turn into much larger problems. Please reconsider this 3 year rule as it is not fair to the patient nor the providers.

      • This is absoulutely correct. As we are a high volume Medicaid office, a one owner parctice) with multiple providers, we also have felt the impact of not being able to give one day service to patients who already struggle with transportation, relative guardianship, and multiple other issues that hinder traetment.

  • Well said !!
    Especially the part about operating under the guise that this helps the state.
    The only people who win are the insurance companies and that’s it.

    The state will still be on the hook for the bigger more expensive treatments that will result from ignoring decay for 3 years! And for those patients that lose their coverage, well they’ll eventually end up at the local ER.

    As a practitioner, we get letters every year around this time encouraging us to buy more supplies because (surprise surprise)prices go up in January, again. There will come a time very soon that this no longer makes sense for anyone, and the people who suffer the most are the most vulnerable.

    Greed will always lead to downfall.

  • Agree with the doctor’s letter. The three year rule and lack of proper pre authorization from DMOs has been a detriment to patient care and doesn’t take to account the statistics this doctor wrote about with very vulnerable portion of the population having more recurrent decay, lack of proper oral hygiene.

    With the increase in costs of materials and labor, and no increase in fees, with these restrictive rules which don’t follow the statistics. Us dentists will struggle across the board, which leads to the question who is really benefitting? The patient isn’t. The dentist isn’t. It’s just the DMOs and THAT needs to be looked into

  • These DMOs are constantly trying to find ways to exclude and withhold from patients in severe need. It’s despicable.

  • You may want to address the problem with corporate (hedge fund, investor backed) dentistry that has changed dentistry and pushed dentists to be overly aggressive with treatment to the point of committing abuse and fraud all at the expense of profit. This is a big part of why so many repeat billings happen. Too many dentists trying to get money off the same tooth. What are plans supposed to do? Just keep paying for restorations over and over and over with no credible evidence that there is a need for re-treatment. It’s always the same old argument – Medicaid children have historically poor dental hygiene? It used to be that the word of a dentist was good enough, but corporate dentistry has injected the greed factor and insurance carriers (not only Medicaid lines of business) can no longer just take the word of the dentists as absolute truth. They are overwhelmed with claims like this. If recurrent decay and restoration failure are the real problem like the dentists claim, it seems they would welcome an opportunity to show the DMOs endless examples on appeal. Look at your profession itself, it has created a big part of the problem.

  • These DMOs are a complete joke. The 3 year rule has destroyed our offices. Every year our costs keep going up and the reimbursement fees keep going down.

  • There is some support for the concept of a class-action legal action against dentaquest and mcna on behalf of the patients they are claiming to serve. This is a different level of callousness and greed, and it will come back to bite them hard. When it does, the repercussions need to be severe.

  • This article could not be more true. Healthcare gravely suffers and collapses when insurance companies chase the almighty dollar at the expense of the provider and more importantly the patient. We have seen this for years with Medicaid but recently their actions border on criminal. We are not at a tipping point but at a collapsing point

  • The insurer to the most vulnerable patients uses rules like the 3 year rule to hold on to the claim that they are helping the public good but in reality are just cost-cutting measures that put the pain and financial burden on patients and dental providers.

  • Imagine having a toothache or decay and you have to wait 3 years to get it fixed because Dentaquest decided that was an appropriate amount of time! This is ridiculous!

  • The 3 year rule is outrageous and illogical. It’s hurting the large community of children in low income families and the small dental offices serving them. The DMOs need to rethink this rule which only serves them and not the greater good. Texas Gov. needs to step in and change this rule.

  • Dental costs have gone up but reimbursements have not, furthermore the DMOs add obstacles such as the 3 year rule to prevent us from giving the care that is needed. I think this is an in effort to save them money, but its comes at the cost of positive patient outcomes. The literature is clear, we operate in a high risk environment and our rules and reimbursement structure should reflect this.

  • The three year rule has a tremendous impact on both the dentist and the patient population. Pre-Authorizations that are returned approved with a $0 adjusted reimbursement rate are ultimately an insult the patient population. Many patient families walk to the office for their appointments. Others are limited by proximity of bus stops and public transportation. The three year rule saves these DMOs money, but when offices in these communities can’t afford to keep their lights on, how will the patients have access to dental care?

  • When evaluating healthcare policies the biggest variable to take into consideration when making decisions on guidelines and reimbursement should always be the health of the patient. We all understand that underlying our endeavours, be it the doctors, the state and the insurance companies, are the financial gears that allow all of three players to continue functioning. So yes, we all understand, it is a business, but not at the cost of the patients’ health and the provision of timely treatment.

    When DMOs enact a rule, such as the three year rule, the patient’s health should be at the forefront, and I find it very difficult to find any evidence based literature that supports such a timeline. So then, when trying to understand the reason behind this three year enactment we are left with nothing more than a financially-driven decision sprouting from within the boardroom discussions at Dentaquest. When restorations fail after a year or two, us doctors are left with the moral pressure to treat or not to treat, at no charge, while Dentaquest turns a blind eye to the responsibility of providing care to patients, which is their job!

    If these patients go untreated while they wait for the three years to pass and consequences arise, it is the shoulders of the State and the doctors that bear the burden of liability, while the DMOs wipe their hands clean. The State took a large legal and financial loss 15 years ago for this very same issue, young children seeking timely care but not finding it due to reimbursement limitations. The State will carry the heft of the weight of any consequences arising from untreated children because of restrictions that bind the hands of us doctors.

    It is high time that DMOs loosen restrictions that are not founded on scientific evidence, restrictions that they enact based solely on financial considerations, and allow the doctors to do their job with the health of the children at the forefront of everyone’s priority list. It is time that Dentaquest reduces the 3 year rule, to allow us doctors to do our job in taking care of our young patients with their health and safety in mind with scientific and evidentiary foundations, while not forgetting the financial machinations that allow us all to continue providing that care. We can all be moral and ethical, and still function as a business together. Reimbursement decisions not grounded on medical evidence, and solely founded on financial reasons should be stopped. Reduce the 3 year rule immediately!

  • The DMO’s 3 year rule is a disservice to the underprivileged community. The vast majority of these children have a higher than average caries rate and will suffer from this insane rule. How can you logically put a time limit on when a patient receives treatment. I can’t imagine the amount of oral health issues these kids will have from the lack of treatment that will be with held due to this. These decisions are based on greed and a lack of compassion.


    Be careful that the dentists on your website are not the DSO’s who are crying about this rule change. There is never enough money in the coffers to appease the profit driven hedge funds and equity firms. Why is TDMR so afraid to post something on their website that is so widely published as being the downfall of a respected profession? A highly reputable dental expert (and practicing dentist) published this article in 2020 and described how this on-going and increasing problem is symbiotic and not just a problem with the MCOs. The profession has done its part to force their hand.

    The article even mentions the Texas Orthodontic debacle and we all know TDMR can’t resist bringing that up every two or three months. Perhaps the MCOs are trying to impose policy to prevent the next great dental debacle in Texas Medicaid?

  • That 3-year rule is NOT problematic for many DSOs. They simply shift service to a different provider in their operation. Sometimes, they simply bill under a different provider’s credentials (identity theft). It’s the smaller solo providers who get screwed. BTW- the DSOs know all this. – Michael W Davis, DDS- Santa Fe, NM

    • Dr. Davis, do you think a dentist with a patient review like the following should be investigated for fraud? “The only problem in my mouth remains the work done by Davis. Crown constantly catches food and needs excessive flossing, but he knows best as he wakes up from his nap to banter with his assistant during your appointment. While they brag about their work, you’re left paying an excessive bill with no recourse but to pay more for them to fix their mistake. First thing they want is your cash or ability to pay. Do yourself a favor and hold back 20% as you do with any contractor pending successful job. You will not find it with Davis!”

    • Callously and offhandedly dismissing patient concerns. Yeah, that is what the review was about. Bet you didn’t even check to see if it was one of your patients. Based on your arguments, your good reviews are fake too. Unbelievable. So it is likely your reasoning on DSOs is pretty spurious as well. Dare we ask for some proof?

  • I’m not a TX dentist. I practice in MD but I agree with the comments here. Dentaquest is a corporation and are driven by numbers. I think doctors, through legislators or even through a pool of funds should challenge dentaquest in a court of law to expose their internal policy making practices. The 3-yr rule along with other crazy made-up ones such as not allowing mobile clinics to operate without their approval(which they will not approve with any excuse they possibly can come up with) all have a financial backing to them and yes, the only beneficiary is Dentaquest. It is time for the beast to be exposed. Dentists do hard work and majority of patients in Dentaquest’s networks are under-served and oral health illiterate. So, they won’t return to their follow up visits like a PPO/FFS patient. I treated some anterior teeth with extensive fractures involving facial, incision and lingual surfaces and they would state that they won’t cover those due to poor prognosis. They literally expect the dentist to see the patient and not treat for anything and let the teeth just rot to the point where it can only be extracted and I can bet that at that point, these patients won’t even care to get them pulled. The ER will have to deal with their abscesses over the weekends.

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