State Alleges Xerox Instructed Dental Staff to Approve HLD Scores of 26 or More Automatically Starting in 2004

ACS XeroxIn the lawsuit against Xerox filed by the Texas Attorney General, there is one more startling revelation.

The State is alleging that Xerox as early as 2004, when the company took over the contract as the state’s Medicaid claims administrator, the lead contractor in the Texas Medicaid and Healthcare Partnership, immediately changed the Medicaid orthodontic prior authorization process.

Xerox changed the Medicaid ortho prior authorization process in 2004 

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 submitted as part of contract]. 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.

No action taken by HHSC to detect or correct it over seven years despite $1.1 billion spent!

Perhaps it needs to be pointed out, that if these allegations are correct, Xerox operated the Medicaid orthodontic prior authorization process in this manner without real detection, change and definitely without intervention from HHSC from 2004 to almost the end of 2011, a total of seven years. $1.1 billion went through the program per the legal documents.

The lawsuit goes on to state about Xerox’s “dental specialists”:

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.

Investigation needed

Again the question must be raised – why was HHSC so negligent?

An investigation needs to be done.

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