Medicaid Dental Stakeholders Meeting.

Transcription

1 Medicaid Dental Stakeholders Meeting April 24,

2 Webinar Broadcast This presentation is broadcast in Webinar format with the integrated speakers and microphone of your own computer which happens automatically If you do not have speakers on your computer dial in to the conference call number provided Webinar attendance requires registration at: 2

3 Format for Stakeholders Meetings Stakeholder Meeting announcements ncements are posted on the HHSC website at: state tx Sign up for automatic ti distribution ib ti the moment the announcements are posted at Announcements and agendas are posted about 4 Announcements and agendas are posted about 4 weeks prior to Stakeholder Meetings 3

4 Format for Stakeholders Meetings Distribution tion lists for personalized ed broadcast is based off Webinar attendance, which captures addresses automatically Stakeholder meetings are held Quarterly: - next occurrence on July 31 st, 2013 at 1pm - subsequently on October 30 th, 2013 at 1pm t ti / i t /

5 Format for Stakeholders Meetings Questions posed today were submitted in advance at: tx Today s presentation ti will be posted on the HHSC website Webinar archives of this meeting posted at: hh t t t / /W present.asp 5

6 Questions during the Meeting - Voting The chat function of the webinar will be used to request feedback from stakeholders during this meeting. The chat box is located at the bottom of the webinar control panel. All chats are recorded and captured automatically. We will be using your responses entered today in the chatbox.

7 After The Meeting Question and Answer Representatives es from the DMO s are available at the rear of the room for 30 minutes after this presentation. They will have internet access but may not be They will have internet access but may not be able to answer specific claim questions

8 Introduction of Speakers Managed Care Organization (MCO) Dental Directors Dr. Carlos Garcia, MCNA Shannon Turner, MCNA Dr. Monica Anderson, DentaQuest Brenda Walker, DentaQuest State Agencies (HHSC) Gary Jesse Emily Zalkovsky Rudy Villareal Colleen Grace Katy Walter JR Guest Speakers 8

9 Regional Stakeholder Meetings In January 2013, HHSC organized regional dental stakeholder meetings around the state; each meeting was a town-hall format. Staff facilitated meetings with more than 300 participants in 11 cities including, Amarillo, Corpus Christi, Dallas, El Paso, Fort Worth, Houston, Lubbock, McAllen, San Antonio, Weslaco, and Tyler. All meetings were open to the public. The purpose of these meetings was to allow stakeholders a specific opportunity to share feedback on successes and challenges associated with the transition to dental managed care in March of At each meeting representatives from HHSC and the two dental plans were present to field clinical and policy questions. Topics discussed included d potential ti ways to enhance communication regarding policy and process changes, clarification on dental claims, appeals and prior authorization process, main dental home requirements, and credentialing. The remaining 2013 quarterly meetings are scheduled for April 24, July 31 and October 30. Each meeting will be held in Austin and will include an opportunity for participation via webinar.

10 Issues and Lessons Learned from Regional Stakeholder Meetings December 2012 January 2013 Katy Walter

11 Regional Stakeholder Meetings Vote 1 Were the regional Stakeholder Meetings conducted throughout Texas in January beneficial to you? How? What further input and advice about the structure of future regional meetings would you like to share? What worked? What didn t? 11

12 Fluoride Payments Procedure code D1208 is a new 2013 HCPCS code It replaces the CDT 2011/2012 codes o D1203 o D1204 Statement from DentaQuest and MCNA Statement from TMHP D1208 code is denied on a submitted claim so that way the rest of the services billed on that claim can process and pay. Once the rates are established (4/1/13) then TMHP will pull all the impacted claims submitted with code D1208 and reprocess them for payment consideration. No further action is necessary from the provider. The reprocessing efforts should begin in April and will take a few months to complete 12

13 TMPPM Online Fee Lookup Client Age Non-facility Facility TOS TOS Desc Pro c Co de M o d 1 M o d 2 Fr Th Uni m ru ts Total RVUs / Base Units Conve rsion Facto r Medic Fee Adju aid Effect st Fee Date Adju sted Fee for Rep ort Date Last Note Prici Note Conve Fee Cod Medi Adju ng Codes rsion Effec es caid st Revi Facto t Fee % ew r Date Adju T sted Date otal Fee RVUs for 123 / Rep Base ort Units Date W THSTEPS DENTAL/OR D1 25 Mon $ $15.0 9/1/2 $14. $ $15.0 9/1/2 $14. 1/1/ THODONTIA ths W THSTEPS S DENTAL/OR D1 THODONTIA Mon ths 0.00 $ $ /1/ $ $ $ /1/ $ /1/

14 TMPPM Fees for Fluoride Adjust % in the Online Fee Lookup Adjusted Fee for Fluoride Codes Client Age Non-facility Facility TOS TOS Desc Proc Code Mo d 1 Mo d 2 Frm Thru Units Total RVUs/ Base Units Conversion Factor Medicaid Fee Fee Effect Date Adjust % Adjusted Fee for Report Date Note Note Codes Codes Conversion Medicaid Fee Effect Adjust Adjusted Total Factor Fee Date % Fee for RVUs/ Report Base Units Date Last Pricing Review Date W THSTEPS DENTAL/ORTHODONTIA D Months 0.00 $ $ /1/ $ $ $ /1/ $ /1/2013 W THSTEPS DENTAL/ORTHODONTIA D Months 0.00 $ $ /1/ $ $ $ /1/ $ /1/2013 D1203/1204 adjusted at -2.00% $15.00 minus 2% is $14.70 D1208 adjusted at 0.00% = $

15 Fluoride Vote 2 Is the process for submission of Fluoride codes clear? Do any of you require a reach out from TMHP Provider Relations for clarification? NOTE: CDT 2014 codes will become effective on January 1, 2014!! 15

16 Texas Medicaid EHR Incentive Program: Dentists Medicaid Health Information Technology (HIT) Team Year 1: Adopt / Implement / Upgrade Year 2: Meaningful Use)

17 EHR Incentive Program 769 dentists in Texas have received incentive payments for AIU (Adopt / Implement / Upgrade) which means that they have acquired and/or installed certified EHR technology. That technology could include a web-based system or software. This 769 represents 14% of all eligible professionals who have received an AIU payment. 17

18 EHR Incentive Program 9 dentists in Texas have received incentive payments for Stage 1 Meaningful Use (MU) which means they have met the program and reporting requirements for the first year of Meaningful Use (meaningful use measures, clinical quality measures, etc.). This represents 1% of all eligible professionals who have received an MU payment. Note: Dentrix Enterprise submitted their application in March 2013 to the testing body for Meaningful Use certification. Quote: Our application is being reviewed and we will soon have a testing and certification date scheduled -Max Sessions, Product Management, Dentrix Enterprise 18

19 The Program in a Nutshell Incentives of up to $63,750 are available for the adoption and meaningful use of certified electronic health record (EHR) technology: AIU (Adopt, Implement, or Upgrade) in the first year of participation i Meaningful Use (MU) in up to 5 subsequent participation years. Eligible Professionals (EPs) include dentists, along with 4 other provider types. First year payment can be received in 2011 through Final payment can be received up to 2021 for EPs. At least 50% of all encounters must be at a site or sites with certified EHR technology. 19

20 Patient Volume Threshold Payment Year by EP Type Medicaid Patient Volume * Incentive Amount Max. cumulative incentive over 6 years Year 1 for most EPs Years 2-6 for most EPs 30% or higher $21,250 30% or higher $8,500 $63,750 Year 1 for pediatricians and pediatric dentists 20% to 30% $14,167 Pediatric dentists are eligible for the lower patient volume threshold of 20%. Years 2-6 for pediatricians and pediatric $42,500 Pediatric dentists attesting to 20-30% Medicaid patient volume will be dentists 20% to 30% $5,667 required to upload documentation that they are either board certified in pediatric dentistry, or they completed a pediatric dentistry residency. * If the EP practices predominantly in an FQHC or RHC, patient volume threshold is 30% Needy Individual volume (Medicaid, CHIP, uncompensated care, sliding scale). 20

21 EPs: AIU and Stage 1 Requirements First year of program participation: Upload documentation that shows AIU (purchase order, contract, or subscription) Stage 1 Meaningful Use: 20 MU measures 15 from the core set and 5 of 10 from menu set 6 Clinical Quality Measures (CQMs) 3CoreorAlternateCore plus 3 from list of clinical measures of the provider s choice. MU: Must include at least one Public Health measure: 1) Immunizations 2) Reportable Labs 3) Syndromic Surveillance 21

22 How to Register and Attest 1. Register at CMS: 2. Verify enrollment as a Texas Medicaid provider, with an active TPI. If you assign payment to yourself, your SSN must be listed in your TMHP profile. 3. Gather required information and documentation: EHR certification number. Group or individual attestation choice. Patient volume information (numerator and denominator). AIU documentation. 4. Log into the portal and attest. Go to and log in. Scroll down to Manage Provider Account and select Texas Medicaid EHR Incentive Program. For the full checklist of steps: Go to and select Providers; go to the Health IT page and select EHR Program Information from the list on the left; click on Getting Started with EHR Incentive Program 22

23 Additional Resources Learn about the Texas Medicaid EHR Incentive Program through a selfguided e-learning tool: Get technical assistance through the Regional Extension Centers at Review program information on the CMS website: Review additional Texas Medicaid EHR Incentive Program information at: ( tmhp aspx) Learn about a recent study on EHRs and healthcare outcomes: Sign up for updates at and enter your address. On the subscription topics page, go to the Projects section and select Health Information Technology. Submit questions by sending an to HealthIT@tmhp.com or calling , option 4. 23

24 New TDA Website Vote 3 Have you accessed it yet? 24

25 Organized Dentistry at work for you New TDA website!! Texas Dental Association (tda.org) The Texas Meeting San Antonio Convention Center May 2-5, 2013 ( 25

26 Organized Dentistry at work for you Questions to DentaQuest est and MCNA are regularly posed by Organized Dentistry: Texas Dental Association ( (source for today s presentations) ti Texas Academy of Pediatric Dentistry ( Texas Academy of General Dentistry ( 26

27 Texas Dental Association The TDA will conduct its next quarterly meeting with Health and Human Services Commission and the dental plans on April 25, The meeting will take place at the TDA Extension Building. The times are below: DentaQuest MCNA 9:00 AM to 10:35 AM 10:40 AM to 12:15 PM 27

28 Texas Dental Association Main Dentist Assignment and Changes Referrals to Other Dentist Providers for Specialty Care Replacement Sealants by a New Dentist Provider Network Adequacy and Specialist Availability TDA Open Records Request April 2013 Processing Emergency Claims by Other Than Main Dentist Discuss Topics DentaQuest Referrals from a facility (Not Main Dentist) to Multiple Specialists at the Same Time and Claims Payment Dental Work in a Hospital Setting - payment to Hospital and Not Performing Dentist Provider Differences in Reimbursement for Preventive Resins (D1352) between Medicaid and CHIP 28

29 Texas Dental Association Main Dentist Assignment and Changes Referrals to Other Dentist Providers for Specialty Care Replacement Sealants by a New Dentist Provider Network Adequacy and Specialist Availability TDA Open Records Request April 2013 Processing Emergency Claims by Other Than Main Dentist Discuss Topics MCNA Continued D7140 and D7111 definition PRR when does MCNA pay for this covered benefit? Periapical radiographs with Tooth# 29

30 D1206 reporting with OEFV Vote 4 Early Childhood Caries - the most common chronic disease of Medicaid id children. I would recommend that we consider unbundling the current medical CPT code for oral evaluation and fluoride varnish for children up to 36 months. Mary Dale Peterson, MD, MSHCA President, Driscoll Health Plan 30

31 D1206 reporting with FDH Vote 5 Texas Medicaid/CHIP data is being used for reliability and feasibility testing for the Starter Set of Pediatric Oral Health measures, under the supervision of the Dental Quality Alliance (DQA) at the ADA Our External Quality Review Organization (EQRO) has reported our data for FDH visits, recorded by bundled code D0145, as not including fluoride varnish application D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver D1206 topical application of fluoride varnish 31

32 Q: Henry Chu I am writing with regard to the requirement for authorizations for periodontal treatment. We see individuals with special needs who cannot cooperate in office for any type of examination or xrays due to a physical or intellectual disability. Current rules state that we must have authorization before we may provide treatment. For this population, it would require one general anesthetic to do the exam, one general anesthetic to debride and probe, one general anesthetic to provide the scaling and root planning, one general anesthetic to provide the prophy and fluoride. This increases the risk for a patient because the induction and emergence from general anesthesia are the most risky parts of the procedure. Performing these treatments at the same visit under general anesthesia makes the most sense for this population. p In addition, patients are limited to one session under general anesthesia with the current regulations. So these patients would not receive care. I have attached photos of a patient we saw yesterday y who will likely loose all of his teeth. 32

33 A: Special Needs Anesthesia Anesthesia is currently a benefit twice per year per patient. 33

34 HHSC Stakeholders Meeting April 24, 2013

35 Important MCNA Updates MCNA is pleased to announce that Appeals may now be submitted via the Provider Portal. Please be advised that faxing is not recommended for appeals as images sent are not of diagnostic quality. Effective April 15, 2013, the reimbursement rate for D7111 has been increased to $

36 Important MCNA Updates In order to communicate more frequently to our network of Providers, MCNA has also introduced Dental Details, a monthly newsletter outlining items of interest to the Provider community. Also, a new Provider Manual will be coming soon. This single document will replace the Covered Services Manual and the current Provider Manual.

37 Narratives A detailed narrative should include the following: Specifics of tooth #, surface, and/or location involved A description of any medication dispensed, how it was given and how much was given Details including any symptoms the patient was having such as pain, swelling, and/or infection. Any compromising medical or physical condition of the patient When applicable please include duration of procedure performed

38 Questions and Answers Thank you!

39 DentaQuest t Dental Stakeholders Meeting April 24, 2013

40 Important DentaQuest Updates DentaQuest is pleased to announce that Appeals and Peer to Peer requests may now be submitted electronically via the Provider Portal. Please visit for additional training information. DentaQuest changed the layout of the Texas Roundup to enhance the provider experience. The bi-weekly publication has been a part of provider education since the start of the program and is posted on the portal and DentaQuest has implemented the PURL process which allows providers to receive alerts when critical information is posted to the portal. An updated Office Reference Manual (ORM) was posted January 29, Going forward, providers will be notified via the portal and PURL process of any changes made to the manual.

41 Best Practices Training DentaQuest has added Best Practices Training based on Provider feedback during the statewide Stakeholder meetings. Best Practices Training includes the following: Understanding the Office Reference Manual Most common denial reasons Medical necessity Clinical criteria Narratives X-rays/photos Appeals process Please visit for training dates and copies of the PowerPoint. In addition, office training can be scheduled by contacting your Provider Relations Representative.

42 Reporting Marketing / Soliciting Violations Any incidents of Marketing / Soliciting violations may be reported to your Regional Provider Relations Representative. A list of Representatives can be found at under Provider Information, Training. i DentaQuest investigates all reports which includes, but is not limited to the following: Research the report to see if we can validate first hand Contact the provider and provide additional education as needed Cease and desist letter to the provider for subsequent violations

43 Questions and Answers Thank You!

44 Complaints Providers can appeal claims denials through the dental plans process outlined within the provider manual. If the provider has exhausted the appeal process and is still not satisfied, the provider may request a peer- to-peer review to resolve the claims dispute. The determination of the provider resolving the dispute is binding. If the provider has exhausted all avenues with the dental plan, they may file a complaint at the following address: HPM_Complaints@hhsc.state.tx.us 44

45 Provider Relations TMHP (tmhp.com) DentaQuest (dentaquesttexas.com) (800) MCNA (mcnatx.net) Internal Reps External Reps 45

46 Solicitation of Patients TAC (d) (1) states MCOs and providers shall not conduct any direct contact marketing except through enrollment events This does not infer that providers can not do mail outs to current clients OIG - $10K fine (next slide) Per HPO, see the definitions of Marketing (second slide) 46

47 Consumers Urged to Report Improper Solicitation or Treatment by Dentists The HHSC Office of Inspector General has become aware of dental clinics directly soliciting Medicaid clients. People hired by dental clinics have approached HHSC clients in the parking lots of state benefit offices or neighborhood grocery stores offering a variety of incentives, including free gift cards, pizzas, and manicures, in exchange for taking their children to a specific dentist or clinic. Offering inducements to Medicaid clients is a violation of state and federal law and is subject to a penalty of up to $10,000 per violation. In addition, some dentists are believed to have performed unnecessary dental work on children. To report this or any other suspected act of fraud, waste, or abuse in the Texas Medicaid program, please visit: to Report Fraud click on link or call

48 Definitions of Marketing HHSC Terms and Conditions Contract definition of marketing: any communication form the MCO (or dental contractor) to a Medicaid or CHIP Eligible who is not enrolled with the MCO (dental contractor) that can reasonably be interpreted as intended to influence the Eligible to: (1) enroll with the MCO (dental contractor) or (2) not to enroll, or to disenroll from, another MCO(dental contractor). UMCM Chapter 4.3 definition of marketing: any communication, from an MCO to a Medicaid or CHIP Client who is not enrolled in the entity, that can reasonably be interpreted as intended to influence the Client to enroll in that particular MCO s Medicaid or CHIP product, or either to no enroll in, or to disenroll from, another MCO s Medicaid or CHIP product CMS definition of marketing (42 CFR ): means communication from an MCO to a Medicaid id recipient i who is not enrolled in that t entity, that t can reasonably be interpreted as intended to influence the recipient to enroll in that particular MCO s Medicaid product, or either to not enroll in, or to disenroll from, another MCO s Medicaid product. Marketing materials is similarly defined (by HHSC and CMS) as: materials produced in any medium by or on behalf of the MCO (dental contractor) and can reasonably be interpreted as intending to market to potential members. 48

49 Texas State Board of Dental Examiners Professional Conduct in Business Promotion Soliciting or securing patients Oral solicitation it ti Patient referrals New patient gifts 49

50 Soliciting or Securing Patients Criminal offense and professional violation to: offer to pay OR agree to accept any remuneration for soliciting or securing patients No recruiters! No compensated referrals! 50

51 TSBDE Oral Solicitation of Patients One-on-one one solicitation of patients prohibited. DPA Sec bars oral solicitation it ti of patients directed to an individual or a group of less than five individuals. Unprofessional to intimidate or exert undue pressure or undue influence over a prospective patient DPA

52 Relevant Rules and Laws Board Rules Business Promotion: Rules to Fee-splitting: Rule 108.1(6) 1(6) Referral Schemes: Rule Texas Law Patient Referral and Solicitation: TOC Oral Solicitation: DPA (2) Advertising Rules: DPA

53 TMPPM reformat of fields CDT Age Tooth Surf Freq Limit PA Docu Clinic menta al tion D0100 to D To 999 A-T, 1-32 M,O,D,L,B/F Yes or No 53

54 TMHP reformat of fields Standardize the format of TMPPM dental policies with medical policies More importance that the clinical efficacy of the therapy Comprehensive listing of the variables associated with each code could be listed This will become a resource document and will communicate far more effectively what is covered, when it is covered and what documentation is needed for submission 54

55 TMPPM reformat of fields Vote 7 CDT Age Tooth Surf Freq Limit PA Docu Clinic menta al tion D0100 to D To 999 A-T, 1-32 M,O,D,L,B/F Yes or No 55

56 Orthodontic Policy Vote 8 Redefinition of Medical Necessity for Ortho handicapping malocclusion so severe it requires surgery to correct 56

57 Adjournment THANK YOU FOR BEING A TEXAS MEDICAID AND CHIP PROVIDER!!! Thank you for your participation via webinar If you have registered for this webinar or you signed in at the rear of this room you are on the Distribution List for our next webinar: July 31,