Plan Termination For Filing a Complaint with HHS Not In DMO Provider Manuals

After our last article about possible termination from a DMO's network for filing a complaint with HHS before all company complaint procedures have been exhausted, we picked up online copies of the Medicaid Provider manuals for DentaQuest, MCNA and UnitedHealthcare Dental to see what they had so say.

Nothing in the manuals about it

Our review found that the manuals didn't say a word about it specifically.

All three manual mention a complaint to HHS is an option

All three DMO manuals mention in their provider complaint section that providers have the option of filing a complaint with Texas HHS.

Only the DentaQuest manual states that providers must first exhaust all company remedies before filing a complaint with HHS. "If a provider is not satisfied after completing the DentaQuest Complaint Process or feels that they did not receive due process, providers may file a complaint with HHSC. A provider must exhaust the DentaQuest Complaint Process before filing with HHSC (p. 39, DentaQuest Provider Office Reference Manual)."

Unfortunately, to take up an issue with them, they make you write to their office in Milwaukee if you want to give them something in writing. Not very Texas friendly.

On the other hand, both MCNA and UHD state in their manuals that providers "have the right to file a complaint directly" with Texas HHS. (p. 70, MCNA Provider Manual: Texas Medicaid and CHIP; p. 18, UnitedHealthcare Texas Children's Medicaid Dental Services and CHIP Dental Services Provider Manual). This is great.

MCNA is even nice enough to give you a San Antonio address if you have a complaint.

Unfortunately, UHD makes you write to Milwaukee too.

Not mentioned in reasons for termination but...

Now, just because the manuals don't indicate a penalty on complaining to HHS without exhausting company processes, this doesn't mean there isn't something in the actual provider agreements that allow it. The Provider Manuals for each company don't list all the reasons for provider termination and refer to their provider agreements about the matter. We don't have copies of the agreements to review.

It is interesting to note that the MCNA Provider Manual states that "engaging in conduct injurious to MCNA's business reputation" is a cause of immediate termination (p. 41). Would a premature complaint be considered such conduct?

DentaQuest is quite clear that termination is at their discretion. The manual doesn't say much about the reasons only that a "provider agrees to comply with applicable state laws, rules, and regulations and HHSC's requests regarding personal and professional conduct generally applicable to the service locations; and otherwise conduct themselves in a businesslike and professional manner." (p. 77)

Their manual goes on to state in its section on credentialing that "nothing in this Credentialing Plan limits DentaQuest's sole discretion to accept and discipline Participating Providers... or DentaQuest's ability to terminate a Provider's participation in accordance with the Participating Provider's written agreement...(p.77)  So, again, a premature complaint would be cause?

UHD's manual provides a healthy section on provider termination and breaches of their Provider Agreement, although it doesn't list all such breaches. However, these rightly focus on quality of care issues. "Providers who are found to be in breach of their Provider Agreement or have demonstrated quality of care issues are subject to review, corrective action, and/or termination in accordance with approved criteria. (p. 11)  To be quite frank, if the manual is any indication, UHD is straightforward and is not concerned if a provider exercises their right to complain to HHS.

Ridiculous to terminate a provider for a complaint

After all, it would seem to be a ridiculous and counter-productive action by a DMO to terminate a provider who has the right to complain to HHS and does so.

We would hope these large and dominating companies would even look at articles published about them on TDMR in the same light. Our purpose here is not to embarrass them but to bring to light and air provider grievances that are not being heeded.

In the long run, by paying attention to such complaints and fixing those things, these companies will improve their operation and serve better the people of Texas.

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