Myths Money & Medicaid Dental Society of Western PA

Transcription

1 Myths Money & Medicaid Dental Society of Western PA Allegheny County Dental Task Force Dr. Karen Hacker, ACHD Dr. Michael Madden, Gateway Health Dr. Nicholas DeGregorio, UPMC for You Dr. Richard Celko, UPMC Health Plan January 18, 2017

2 Agenda Welcome and Introductions Allegheny County Dental Task Force ACHD Dr. Karen Hacker Medicaid: Overview and Barriers Gateway Health Dr. Michael Madden Medicaid Enrollment UPMC Dr. Richard Celko Revenue: Medicaid Reimbursement Rates and Incentive Plans UPMC Dr. Richard Celko Questions

3 Allegheny County Dental Task Force Dr. Karen Hacker, ACHD

4 Melissa Allen, ACHIEVA/The Arc of Greater Pittsburgh Debra Caplan, PHA Access Work Group Co-chair Dr. Richard Celko, UPMC Health Plan Kyle Craig, ACHD Dr. Nicolas DeGregorio, UPMC Katie Domalakes, UPMC Laura Fennimore, UPMC for You Dr. Karen Hacker, ACHD Dr. Rod Harris, ACHD Lynda Jones, ACHD Susan Kalson, Squirrel Hill Health Center Dr. Michael Madden, Gateway Health Joseph Mastalski, Gateway Health Casey Monroe, ACHD Dr. Deborah Moss, Children s Hospital of Pittsburgh Dr. Deb Polk, University of Pittsburgh School of Dental Medicine Dr. J. Mark Prybyl, Catholic Charities Free Heath Care Center Dr. Sandra Thompson, ACHD Dr. Robert Weyant, University of Pittsburgh Dr. Dennis Zabelsky, Dental Society of Western PA Allegheny County Dental Task Force Members

5 Allegheny County Dental Task Force The Allegheny County Dental Task force was created through the Plan for a Healthier Allegheny, under the Access priority area In 2015 the PA Department of Human Services ranked increasing access to dental care as their number one priority Allegheny County Dental Task Force agreed to address the following issue: Increase the number of Allegheny County residents receiving dental care 1. Exercise around data and reporting frequency 2. Exercise around billing for ACHD 3. Education campaign 4. Education around Medicaid model 5. Public health hygienist Task force is initially focusing on children (1-4), then consider adults

6 Methodology Gateway Health, UPMC FOR YOU, Aetna and United provided preventive dental care claims data by completing data templates Data included Medicaid members meeting the following criteria: enrolled for at least 90 continuous days Allegheny County residents ages 1-20 received at least one preventive dental care service in 2014

7 Data were aggregated Analysis Preventive dental care utilization rates were determined and stratified by: Age Race Gender Zip code of residence Location of Medicaid-accepting practices were mapped to determine dental deserts

8 Key Findings Utilization of preventive dental care in pediatric Medicaid population does not differ by gender or race Varies significantly by age Utilization was lowest among children ages 1-4 Age (Years Days) Number of Medicaid Patients % % % % % % Received at Least One Preventive Care Service in 2014 Utilization was highest among school-age children but still below 60%

9 Age (+364 days) Number of children in Allegheny County enrolled in Medicaid who utilized preventive services, by age (year +364 days), Number Combined Medicaid Members 6079 Number Utilizing Preventive Services * Data includes UPMC FOR YOU for You, Gateway Health, Aetna, and United Medicaid claims data from members who were enrolled for at least 90 continuous days. A member was considered to have utilized preventive services if they had at least one preventive CDT claim (CDT codes D1110, D1120, D1206, D1208, D1310, D1320, D1330, D1351, D1353, D1352, D1510, D1515, D1520, D1525, D1550, D1555, D1999) during the 2014 calendar year.

10 Percent Age

11 Key Findings Utilization of preventive dental care varies by zip code for children ages 1-4, yet remains low Most areas of Allegheny County experience utilization rates well below 50% Areas with higher utilization tended to have fewer Medicaid members Utilization rates in zip codes with a high number of Medicaid members ages 1-4 (500+) range from 18.9% to 34.0% No clustering of zip codes with the lowest utilization rates was observed

12 Percent utilization of preventive care among Medicaid members between ages 1 and 4 years (+364 days) and the location of practices that accepted at least one these members during the 2014 calendar year * Data includes UPMC FOR YOU for You, Gateway Health, Aetna, and United Medicaid claims data from members who were enrolled for at least 90 continuous days. A member was considered to have utilized preventive services if they had at least one preventive CDT claim (CDT codes D1110, D1120, D1206, D1208, D1310, D1320, D1330, D1351, D1353, D1352, D1510, D1515, D1520, D1525, D1550, D1555, D1999) during the 2014 calendar year.

13 ZIP Codes with the largest population of Medicaid members between ages 1 and 4 years (+364 days) and the location of practices that accepted at least one of these members during the 2014 calendar year. Zip Code Number of Medicaid Members, 1-4 Years Percent Utilization % % % % % % % % % % %

14 Next Steps to Address Concerns: Pitt Dental Student (SCOPE) located at McKeesport Clinic Assessing capacity to use Public Health Dental Hygiene Practitioner (PHDHP) model Enhancing insurance capacity Expanding clinic sites ACHD Dental Program Three clinics: Central City (Hill House), Mt. Oliver, McKeesport Preventive and corrective treatment for children 1-20 years of age Services include: examinations, cleanings, fluoride treatments, x-rays, fillings, extractions, and sealants Approximately 12,000 patient visits are provided each year Dental Health Promotion Each year we provide on request Dental Health Education to Head Start Classes, Homeless Shelters, Community and school health fair, Day Care Centers

15 Medicaid: Overview and Barriers Dr. Michael Madden, Gateway Health

16 Source: PA Department of Human Services June 2015 PA Medical Assistance Program Dental Fee Schedule Children under 21 years of age are eligible for all medically necessary dental services Children under 21 years of age who require medically necessary dental services beyond the fee schedule limits, the dentist should request a waiver of the limits, as applicable, through the 1150 Administrative Waiver (Program Exception) process Provider types 27 Dentist and 31 Physician are the only provider types eligible to receive payment for dental services Provider type 31 (Physician) is eligible for payment only for procedure codes D7450 through D7471, D7960 and D7970. (This does not exclude provider type 27 Dentist.) Provider type 27 (Dentist) who is a board certified or board eligible orthodontist is the only provider type eligible for payment of orthodontic services PHDHP s working in public health settings and supervised by a dental provider can also bill for services

17 Benefits for PA, Medicaid InsureKidsNow.gov Date: January 6, 2017 Data as of: 06/23/2016

18 Benefits for PA, Medicaid InsureKidsNow.gov Date: January 6, 2017 Data as of: 06/23/2016

19 Reducing Dental Disparities in Medical Assistance Dental caries are the most chronic infectious disease in children o 42 percent of children ages 2 11 years have dental caries o Increasing prevalence in the 2 5 year age group 1 Children from low income families have 2X the rate of caries 2 o More often have severe decay at an earlier age o Require more extensive restoration by their 1 st dental visit There are racial & ethnic disparities in dental care for African American & Latino vs. White & Asian American kids with Medicaid 3 o For the % who never had a dental visit o In the time interval since the last dental visit o In time since last visit for kids with MA vs. Commercial insurance o In time since last visit within the MA insured population 1. National Health and Nutrition Examination Survey (NHANES), Oral health in America: A report of the Surgeon General. Rockville MD US NIH, National Institute of Dental & Craniofacial Research, 2000;63: Pourat N et al. Racial & Ethnic Disparities in Dental Care for Publically Insured Children. HealthAffairs, July 2010;29(7):

20 Fishbone Diagram

21 Reducing Dental Disparities in MA Oral health is integral to general health. US Surgeon General s Report Children with dental problems often experience: Provider More missed school days Delayed physical growth & development Increased costly ED visits Greater risk of additional caries Member Improving Dental Care Health Plan Siblings with greater caries risk Breaking the disparity cycle requires: Greater access / participation by dentists in the PA Medicaid Program More dental education for MA members Strong dental provider payer partnerships

22 Reducing Dental Disparities The greatest disparity in dental care is in the youngest, most vulnerable 0-5 age group: The AAPD and AAP recommend: The first oral examination at the time of the first tooth eruption and no later than 12 months Establishing a dental home at age 1 Application of fluoride varnish & sealants as appropriate Age 1 Connect the Dots Training is available Free and provides 2 CE credits Provides training in risk factors, knee-to-knee exams, and anticipatory guidance for parents Describes the business model: practical strategies for billing and increased productivity by incorporating infant visits

23 Discussion: What are the barriers dentists experience to accepting Medicaid?

24 How to Enroll and Accept Medicaid Dr. Richard Celko, UPMC

25 How to Enroll as a PA Medicaid Dental Provider? PA made it easy with instruction on the PA.GOV Web site: ation/ Enrollment can be on paper or electronic The electronic application guides users through the process and explains how to upload supplemental documents A help number is available to guide you through the process: Provider Enrollment Assistance and help with general enrollment questions Hours of Operation: Monday Friday, 8:00 AM 4:30 PM

26 PA.GOV:

27 Provider Enrollment Electronic Portal:

28 New Application or Revalidation: Dentist

29 New Application or Revalidation:

30 PA DHS Web-based Provider Application Site Navigation Key Points: The Electronic Application UI is a secure internet site: Providers need to create a password for each application Each online provider enrollment application is assigned a unique Application Tracking Number (ATN) Providers can resume a previously started application or check status of a submitted application User must click Finish Later or Save and Continue after completing the information on each page in order for the page information to be saved If inactive > 25 min., the user will receive a message requiring them to respond in order to continue the session If a user does not respond within 5 minutes, the session will end The user can resume their application at a later time

31 Additional Enrollment Resources Provider Enrollment Information: Information about requirements for each Provider Type and links to the Department s provider enrollment forms Provider Enrollment and Screening Requirements of the ACA: Current information from DHS relating to the ACA federally mandated regulations ablecareact/ Medicaid Information: Information about the ACA federally mandated regulations and how they relate to the Medicaid program Department of Human Services Website: MAB Re-enrollment/Revalidation of Medical Assistance (MA) Providers: Provider Enrollment Questions: Includes contact information and help for MA Providers

32 ADA Dental Claim Form

33 Reimbursement Rates and Incentives Dr. Nicholas DeGregorio, UPMC

34 Medical Assistance in Your Dental Practice: The Business Model Billing for the episode of care: Preventive dental visit including 1 of the following: D0120 periodic oral evaluation, established patient D0145 oral evaluation < 3 y/o and counseling parent D0150 comprehensive oral evaluation new or established And 1 of the following: D1110 dental prophylaxis adult or D1120 dental prophylaxis child And 1 of the following: D1206 topical application of fluoride varnish or D1208 topical application of fluoride, excluding varnish And application of dental sealants when appropriate Medicaid Managed Care Organizations of P4P payments for each preventive dental visit It may vary from plan to plan but is substantial

35 Medical Assistance Dental Fee Schedule: Potential Reimbursement for Evidence-based Dental care

36 Dental Code Potential Reimbursement for a Dental Visit for Medicaid Dental Service MA Fee Schedule Reimbursement D0120 Dental Exam $20.00 D1120 Prophy $30.00 D1206 Fluoride Varnish $18.00 With Sealants TOTAL $68.00 $68.00 D1351 Sealant per tooth $25.00 X 4-8 molars/premolars (4 8) x $25.00 $ $ TOTAL $ $ Add MCO P4P annual payment for closing the dental care gap: amount and frequency of payment may vary by plan Radiographs & Restorative Work would be paid additionally per the fee schedule May range from $ $30.00 $$$

37 2017 Medicaid Incentive Plan Age Type of Visit Payment Amount to Dentist 6 months 5 yrs. New patient $30 6 yrs. 20 yrs. New patient $25 1 yr. 5 yrs. Retuning patient $10 6 yrs. 20 yrs. Returning patient $10 Source: PA Department of Human Services

38 Next Steps: Call to Action Feedback from You Post slides to Dental Society of Western PA Website Continuing Education Opportunity Mass Mailing Information on Incentive Plans Medicaid FAQs Brochure