Title: NORTH CAROLINA MEDICAID DENTAL PROGRAM UPDATE
1NORTH CAROLINA MEDICAID DENTAL PROGRAM UPDATE
- July 16, 2008
- 2008 Statewide Oral Health Conference
2Objectives of Presentation
- Discussion of budgetary trends including latest
strategies for reimbursement rate increases - Discussion of policy initiatives recently
implemented, in progress and planned for the
future - Discussion of access to care measurements
methodologies, recent DMA NC county data and
trends in data - Brief introduction to documentation for the
purposes of payment by third party payers
Federal OIGs Report on Improper Payments for
Medicaid Pediatric Dental Services -
3MEDICAID DENTAL EXPENDITURES
- Increases in expenditures each year from SFY 1990
SFY 2007 (16.8 million to 240 million) - SFY 2008 targeting total expenditures at approx.
270 million after 11 months of the SFY. Over SFY
2007, SFY 2008 expenditures up almost 11 and
total number of recips receiving services up 8 - Dental Program share of Total Medicaid
Expenditures has grown from 1.2 in SFY 1990 to
over 2.5 in SFY 2007 - In terms of growth in expenditures from SFY
2003 to SFY 2007 dental expenditures ranked
second at 86 over the five year period ahead
of physician services, inpatient hospital
services and mental health clinic services. Only
trails non-physician practitioner services-
includes COMMUNITY SUPPORT!
4MEDICAID SERVICES EXPENDITURES SFY 2006
5Growth in Dental Program from SFY 1990 - SFY
2006( of Total Medicaid Program Expenditures)
6Total Dental ExpendituresSFY 1990 SFY 2007
7Top Ten Procedures(ranked by total cost to
Medicaid) Reimbursement Rate Comparisons
8 Reimbursement Rates
- Overhead expenses for an average dental office
are approximately 65 of collections --
procedures reimbursed below 65 of NDAS benchmark
means provider loses money - Adult services (denture, oral surgery, endodontic
and periodontal) still lag behind -- many of
these procedures are at or near the current floor
below 50 of the 2007 NDAS median - Increasing these rates should attract more
specialists (oral surgeons, orthodontists,
endodontists and periodontists) to enroll in
Medicaid - Many preventive and diagnostic services are
reimbursed at higher rates well above 60 of NDAS
benchmark median increased utilization of these
services should lead to cost savings to the
Medicaid program in the future
9 Reimbursement Rates
- Top ten procedures in total cost to NC Medicaid
average at 64 of 2007 NDAS (National Dental
Advisory Service) benchmark - Top ten procedures in total cost account for
roughly 48 of overall dental expenditures - 2003 lawsuit settlement increasing reimbursement
for 37 procedural codes has improved
reimbursement rates for childrens services - Weighted average for all 200 covered services is
approx. 62
10Reimbursement Rates
- More needs to be done to increase reimbursement
rates with a target goal of 75-80 of NDAS
median, but progress has been made over the last
five years - Increases in reimbursement rates to reflect
prevailing market rates should be sustained by
annual rate increases to match the Dental CPI of
4.9 per year. - Increasing rates will create a Field of Dreams
effect Build it and maintain it and they will
come and remain active provider enrollment
will increase - Examples Indiana (1998), South Carolina (2000),
Alabama (2000), Tennessee (2002), North Carolina
(2003), Virginia (2005) -
11Strategies to Increase Reimbursement Rates
- The NCGA has included a special provision in the
State Budget to increase Medicaid dental
reimbursement rates 5 million in state approps
recurring funding over the next two SFYs. - With FMAP and county share this means a little
less than 15 million for rate increases or
between 5-6 of projected SFY 2008 dental budget - Smaller increases make it harder to decide where
the funding should be applied - Some of the funding will be used to cover
increases in inflation, consumption and increased
numbers of recipients receiving services due to
rate increases
12Strategies to Increase Reimbursement Rates
- Increase the floor from 48 of NDAS median
- Pros will increase rates for procedures that are
furthest behind market based benchmarks (UCR)
oral surgery, removable pros, endo, perio, etc.
mostly adult services at or near the floor of
48 NDAS. - Cons
- Will not address lawsuit settlement codes
(childrens services) no increase in these
codes since 2003 - Will result in criticism from some circles in the
provider community
13Strategies to Increase Reimbursement Rates
- Targeted rate increases
- Pros allows increases in the rates for codes
that program staff deem most worthy of increase
based on utilization and other factors - Cons
- May not raise the floor for many services that
lag far behind market based benchmarks - Will result in criticism from some circles in the
provider community
14ConclusionsStrategies to Increase Reimbursement
Rates
- You cant please all the people (providers) all
the time - DMA has employed forms of both strategies in the
last three rate increases since 9/2006. - Zigging and zagging to address needs with
limited funding - Kudos to NCGA for including rate increases in the
budget and to organized dentistry for recent
successful lobbying efforts. - Please, sir (and madam), can we have more?
- We have come a long way since the lawsuit
settlement in 2003.
15Adoption of D0145
- Why?
- Promote the concept of the dental home by age 1
- Encourage dentists to treat Medicaid preschool
children and increase access to oral health care
for this group of recipients - Link the oral evaluation code to the safest and
most effective preventive technique to reduce
early childhood caries (ECC) fluoride varnish
16Adoption of D0145
- What is it?
- D0145 oral evaluation for a patient under three
years of age and counseling with primary
caregiver - Preferably within first 6 months of the eruption
of the first primary tooth - Includes
- Recording the oral and physical health history
- Evaluation of caries susceptibility (assess risk
for ECC) - Development of an appropriate preventive oral
health regimen - Communication with and counseling of the childs
parent(s)/guardian and/or primary caregiver
17Adoption of D0145
- Who can render the service?
- Dentist must complete the diagnostic oral
evaluation and subsequent treatment planning - RDHs, CDAs can complete delegable tasks such as
recording of oral and physical health history,
development of an appropriate preventive oral
health regimen and portions of the evaluation of
caries susceptibility.
18Adoption of D0145 Claims/Billing Instructions
- D0145 must be provided on the same date of
service and billed in conjunction with D1206
(topical fluoride varnish) therapeutic
application for moderate to high caries risk
patients to receive payment for any claim
including D0145. - Why? evidence based research indicates that FV
is the most effective and safest preventive
technique in the battle against ECC
19Adoption of D0145 Claims/Billing Instructions
- Other dental services (except other diagnostic
and fluoride procedures) can be provided on the
same date of service as the D0145 and D1206
diagnostic/preventive oral health service
package. - At age 3 and older, only D0120 is allowed for
periodic visits.
20Claims/Billing Instructions
- Flexibility allowed
- If providers do not wish to apply topical FV
(D1206) to a patient under 3 years of age at a
periodic visit, they may still use procedural
code D0120 to report and receive reimbursement
for the periodic oral evaluation rendered on that
date of service. - Any of the three diagnostic codes (D0120, D0145
or D0150) can be billed for the patients first
visit. However, D0145 must be provided in
conjunction with D1206 -- topical FV to receive
reimbursement for any claim with D0145 . - For follow-up visits D0120 or D0145 can be
rendered every 6 calendar months until age 3.
(Again, D0145 must be provided with D1206
topical FV)
21(No Transcript)
22SamplePeriodicity Schedule for Diagnostic and
Preventive Services for Preschool Recipients
23Policy InitiativesIn Progress
- D2393 resin based composite -- three surfaces,
posterior will eliminate policy limit and allow
procedure on primary molars. Policy limit remains
in effect on D2394. - Considering changing the frequency interval of
D0145 oral evaluation of a patient under three
years of age and D1206 topical fluoride varnish
application to allow as often as every 4 months
for preschool recipients who are identified
through caries risk assessment as susceptible to
ECC.
24Policy InitiativesFuture Plans(That Vision
Thing)
- Improve access for special care patients
- Examine other models
- Enhanced reimbursement Florida, South Carolina
- Adopt D9920 behavior management, by report
Arizona, New Mexico - Training requirements for providers pediatric
residency, GPR, geriatric fellowship, special
care fellowship, AHEC or UNC SOD course limited
to qualified providers - No prior approval for D9920, limitations of
present MMIS to prevent overutilization of code
how do we link recipient medical diagnosis to
eligibility to receive D9920 service?
25Growth in Number of Billing Providers
26Growth in Number of Billing Providers
27Enrolled Providers -- SFY 2007
- 1795 enrolled billing providers with at least one
paid claim - billing providers receive payment
- Approx. 2000 enrolled attending providers with at
least one paid claim - attending providers render treatment
- 3939 active licensed dentists in NC at end of CY
2007 - gt50 of active licensed dentists in provider
network - implications more dentists participate in
Medicaid than typically reported in the media
does not sell papers nor does it necessarily help
those who advocate for higher reimbursement - those greedy dentists may not be as bad as
reported
28Access to Dental Care All Recipients
29 Access to Dental Care lt 21
30Access Measurements SFY 2007 --County Specific
Snapshots
- DMA QEHO has calculated dental access
measurements for children lt 21 and adults gt21
for each NC county - Please see this data along with other interesting
demographic and health care data for each county
at www.dhhs.state.nc.us/dma/countyreports/county
reports.html - Why? to enable policymakers and other
stakeholders a chance to examine and better
understand Medicaid data on the local level -
31Access Measurements SFY 2007 --County Specific
Snapshots
- Methodology for dental access measurements same
as current CMS recommendations on the CMS 416
(line 12a/line 1) - Numerator of Medicaid eligibles receiving any
dental procedure (CDT code) for the reporting
period - Implications for NC this includes preschool
kids receiving IMB services from PCPs and
extenders - Controversial among some pediatric oral health
policy experts Federal EPSDT regs define dental
services as those provided by a dentist or under
the supervision of a dentist - Are physicians permitted by state law to practice
dentistry? YES! - Still, there are naysayers who believe that PCPs
and extenders are not an effective means of
providing diagnostic and preventive procedures
and only fulfilling one piece of the EPSDT regs
requirement for comprehensive dental services
fragmented care should not be counted on line
12a
32Access Measurements SFY 2007 --County Specific
Snapshots
- Denominator any Medicaid recipient eligible for
Medicaid dental services during the reporting
year - Implications any Medicaid recipient eligible
for even one month is included in the access
measurement for the year no requirement for
continuous enrollment - Differs from other accepted access measures like
HEDIS ADV which require continuous enrollment
(HEDIS 11 out of 12 months) see handout for
statewide HEDIS ADV results for CY 2006 - Lack of continuous enrollment requirement has
dramatic effect on Medicaid access measurements
because of the transient nature of Medicaid
eligibility ex. in NC in SFY 2006 approx. 1.6
million recips eligible at any time during the
year, but average monthly eligibility was 1.2
million.
33Access Measurements SFY 2007 --County Specific
SnapshotsTrends
- Data is based on recipient county of residence,
not on where care is obtained - Access for adults poorer than for children
- Some NE and SW rural and remote counties have
access measures well below state average for both
age groups Dare, Camden, Pasquotank, Swain,
Currituck, Perquimans, Bertie and Jackson - Some urban counties with large numbers of active
licensed dentists, enrolled Medicaid providers
and Medicaid recips are a little below the state
average for children Cumberland, Mecklenburg,
New Hanover, Wake. - The ratio of actively participating
dentistsMedicaid recips is low - Some urban counties with the same elements are
significantly above the state average for
children Buncombe, Durham, Forsyth, Guilford
34Access Measurements SFY 2007 --County Specific
SnapshotsTrends/Analysis
- Some of the counties with access well above the
state average for children are not urban
Wilkes, Carteret, Craven, Franklin, Hyde,
Montgomery, Moore, Polk, Wayne, Yancey - Analysis What does it all mean?
- Not entirely accurate to state that urban access
is better than rural for the underserved when
referring strictly to Medicaid recipients - Still need to address access issues in remote NE
and SW counties - Adult access is improving but slowly strategies
to improve? - More training and incentives to providers to
increased access for special care patients - Key ingredients to success not entirely clear
and more detailed analysis is necessary - Hypothesis takes good teamwork between active
public and private providers to achieve success
only limited success without both sides pulling
their weight
35Documentation for Payment Purposes
- Federal DHHS OIGs Report on Improper Payments
for Medicaid Pediatric Dental Services
www.oig.hhs.gov/oei/reports/oei-04-04-00210.pdf
Released September 2007 - NC one of five states examined for CY 2003
payments - Overall results of study 31 of Medicaid
pediatric dental payments were found to be in
error services provided in error estimated to
be about 155 million, of that an estimated 96
million came from the Feds - 24 documentation errors that resulted in
reviewers being unable to determine that services
were medically necessary and/or billed
appropriately - 7 did not meet billing requirements
- 2 were medically unnecessary procedures
- Exceeds 31 because some services had more than
one error
36Documentation for Payment Purposes
- Examples of documentation errors
- 6 -- undocumented errors no record of the
service in the patients chart or service was
unsubstantiated by records submitted - 9 -- insufficient documentation to determine
correct billing - Restoration performed with no identification of
surfaces restored - Surgical removal of impacted tooth with no
documentation demonstrating type of removal - 13 -- insufficient documentation to determine
medical necessity - SSC provided documented in record, no
supporting radiograph - Procedure supported by an inconclusive or
undiagnostic radiograph
37Documentation for Payment Purposes
- 7 billing errors incorrect procedure codes,
services that were not billable because they
violated policy or statute, incorrect number of
units, unbundled services - Upcoding providing a two surface restoration
and billing for a four surface restoration - Downcoding billing a non-surgical extraction
when providing a surgical removal of a tooth - Not billable service two orthodontic
adjustments in the same month violating policy
limit on once per month
38Documentation for Payment Purposes
- Criticism of OIGs study abounds
- OIG substantially overstated error rates -- truly
improper payment rates are probably about the
same in Medicaid as in commercial insurance. - The medical necessity standard is a difficult
standard to apply to dental records because
dentistry, unlike medicine, does not employ ICD9
diagnostic codes no standardization for billing
purposes. Diagnoses can vary depending on the
clinician reviewing the patient records and
radiographs. - Nearly 5 of the claims categorized as
undocumented were records that were not
reviewed because they were not provided by the
subject dentists most studies would eliminate
these from consideration not the OIG!
39Documentation for Payment Purposes
- Too strict in terms of requirements for
documentation - Taking a diagnostic radiograph prior to an SSC
may be very difficult on a preschooler according
to the OIGs study guidelines documenting
necessity based on clinical findings is not
enough - Too strict in terms of what is considered an
error - transcription errors are counted ex. DOS in
patient record does not match DOS on claim form
40Documentation for Payment Purposes
- Lessons Learned
- CMS and States need to do more outreach to
educate providers about the need for better
documentation and to ensure compliance with
policies and State and Federal statutes and regs - CMS and States need to refine prepayment MMIS
audits and edits and develop better post-payment
review techniques that ensure appropriate
documentation is occurring in the provider
community - Providers should take the initiative to seek
training and guidance from the State Medicaid
agencies these resources are available in NC
from both DMA and EDS.
41Division of Medical AssistanceNC MedicaidDental
Program
- www.ncdhhs.gov/dma/dental.htm
- Mark W. Casey, DDS, MPH
- Dental Director
- Mark.Casey_at_ncmail.net
- 919-855-4280