TDMR 2016/2017 Year End Roundup – Bad End, Busy Start

2016 ended very badly for Texas Medicaid.  It was a very poor Christmas for many.  There were a number of important divisive events that occurred which we decided not to comment on during the holiday season.  We didn’t want to spread the distress.

Bad end to 2016

Firstly, the $350 million in cuts to therapy for disabled children kicked in on December 15.  This will affect approximately 60,000 children across the state.  Not much more needs to be said.

Next, in its infinite wisdom, the state through Inspector General Stuart Bowen opted to pursue its political agenda against Planned Parenthood via Medicaid on December 17.  It is an old prosecutorial trick to bring charges against a defendant just before a holiday to create maximum turmoil and upset.  It is not that TDMR agrees or disagrees with Planned Parenthood’s operation.  It is that the state is using Medicaid for political purposes.  Rather than bringing legislation forward to straightforwardly ban the organization in this current legislative session, it is seeking to use Medicaid as its spear.  It is quite frankly reminiscent of what former OIG henchmen Jack Stick and Doug Wilson did with claims of massive Medicaid fraud against dentists to steer blame away from the state for its out-of-control spending on Medicaid orthodontic treatment during their reign of error.  The state’s willingness to do this puts every Medicaid provider at risk.

Lastly, the state got back a little of its own on December 27 when pharmacy giant CVS filed a lawsuit against Health and Human Services.  We’ll just quote the Statesman on this one.

CVS Pharmacy, accused by the state of Texas of defrauding Medicaid of $30.5 million, is suing the state Health and Human Services Commission, claiming state officials approved the billing practices at the heart of the fraud case, court records show.

The lawsuit, filed Tuesday in state District Court, echoes complaints made by dentists and orthodontists who were accused of billing the state for unnecessary procedures from 2007 to 2012, accusations that state investigators struggled to prove in court.


2017 starts quickly

It has been a busy start to the New Year.  The problems that many dentists are having with managed care, especially MCNA, continue to be significant.  We are going to publish here a number of the comments we received over the last few weeks including from some from our President Greg Ewing and attorney Joe Flores from Corpus Christi who has significant experience with Medicaid issues.

Greg Ewing, TDMR President:

“I am disturbed that legislators may now be thinking there was no fraud committed by TMHP/Xerox or judging by Sen. Kolkhorst’s comment, large companies do not indulge in such behavior. Perhaps she was just making a joke.

“Her discussion of the Medicaid orthodontic spending controversy a few years ago is appropriate.  One of the elements of making a case for fraud is determining that a person knowingly makes a false statement with the expectation that someone will rely on that statement. There were false representations made there somewhere.  Those representations are fraud and criminal in nature.  If not by Xerox, who?

“First, the state said those representations were made by dentists.  It was a mass conspiracy of more than 400 dentists to rip off the state.  Five years later, those allegations are in ashes and entirely debunked. Not a single dentist that went to a payment hold hearing was found culpable.

“Then we have the state saying it was Xerox and suing it over the company’s prior authorization process which the state alleged was fraud because they didn’t know that Xerox was rubber stamping tens of thousands of orthodontic requests.

“Now, if it is true that the state hired Xerox to approve all those requests as Sen. Kolkhorst said, and the state knew everything about their process, as the company says, that sort of lets Xerox out of the bag.

“So where is the fraud?

  1. The prior authorization process was totally meaningless.  This was done by Xerox but apparently condoned by the state. That was a fraud.
  1. State actors then told dentists to assume a board-certified orthodontist was reviewing all their prior authorization requests when they knew otherwise.  That is fraud and deceit.
  1. When media exposed the alleged runaway spending (but Xerox was hired to approve these, per comments recently made), state actors went on to fiddle with the HLD scoring as a retroactive “clarification” and claim dentists had 99% error rates to back up their phony allegations of fraud.  The goal was to shake them down for the return of fees honestly earned and bankrupt them if they couldn’t pay.  That is fraud and racketeering.

“The state was on the ground floor here.  We should be looking at big government, not just big companies when it comes to fraud.  The state should be looking at its own hands in this case.  And somebody should be going to jail.

Attorney Joe Flores:

“Why is Health and Human Services not investigating dental managed care organizations?  Why are they not holding them accountable?

“They should be the first ones that should be held accountable regarding any kind of service whether its dental, medical, pediatric or obstetric.  These people are the middle-men, the bagmen for the government. They are collecting the money, then they are deciding whether or not they are going to pay the provider which is wrong.  That needs to stop.  The tail is wagging the dog.”

Keith Coe, DDS:

‘I have taken the steps to disenroll from MCNA. Beware, however, that although you will be required to continue to see MCNA patients for 90 days, they will reassign virtually all of your patients, within two weeks of receipt of your notification to terminate. We are doing everything in our power to get our MCNA patients to transfer over to Dentaquest but I feel certain that we will miss many due to lack of good contact information. Also, it can take up to 45 days for patients to be moved from MCNA to Dentaquest.’


“This is unbelievable….. How does a state that is supposed to be the richest in the US going to cut Medicaid to the neediest? How dare they use my tax money to fund something other than children needing therapy or home health of any kind. I promise I will get as many of the people I am directly connected to start sending letters to our new president coming into office to get this back into a servicing of the neediest program. I am outraged.”

Honest Provider:

“I spent $28,000.00 in attorney’s fees and was investigated by the OIG. Without being long-winded my program was found to be clear of any wrong doings. Since the state did not take my case to a formal hearing I was not refunded the time or the fees. Then I find out the state is suing Xerox!”

Dr. Anonymous:

“Consider yourself lucky. I spent $480,000 on attorney’s fees for my 2010 case, and it was dismissed. Pretty obvious I do not look upon the investigative agents with any fondness.”


“Seems like the MCO’s are the hot potatoes on all this lately fraud issue. The HHS is washing their hands by sending transferring their inefficient administration to third parties that are worse than the HHS itself. Indeed there will be someone to blame and why not the providers?

“It is time for us providers to seek for better legal representation. And stand as one profession.”

Jeff Leston:

“Contract agreements and MCO themselves are to blame. By signing agreements with third parties insurances in this scenario, we are giving away our legal professional rights, patients right, and right to charge properly for services provided. Without providers willing to contract with MCO won’t exist. and corporate practices won’t abuse providers rights as well.

“The problem is that oversight has been left to the MCOs who have no incentive to find and recover fraud unless they keep it. But Mr. or Ms. Dudensing did admit what has been denied for a long time, that fraud is baked into the capitation and other reimbursement rates paid to these plans. Since they are already being paid for it, why bother reducing it if all they have to do is pay the State Treasury back? There is another reason they don’t pursue it; they don’t want to alienate providers. They sold the State on the size and breadth of their network, whom they also need for their commercial business. We all want our providers to be “in-network” and in this environment, providers bring patients, patients bring premium dollars. It is a fools’ errand to assume that the MCOs will jeopardize that”


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