MEDICAID REIMBURSEMENT

Transcription

1 MEDICAID REIMBURSEMENT

2 Medicaid for children under 20 Pays for exam, cleaning, and fluoride treatment every six months. $100 of x-rays per year. Pays for fillings, sealants, extractions, stainless steel crowns, partials, and dentures. Challenges: No payment for fluoride treatment after age of 13. No payment for root canals on permanent molars. Only pays for composite crown not a more durable porcelain to metal crown.

3 Medicaid for Pregnant Women & Adults Pregnant women are covered for exam, cleaning and fluoride treatment every six months. Fillings, extractions, periodontal treatment are covered up until the baby is delivered. Adults - Pays for exams, x-rays, and extractions. Adult Challenges: No payment for cleaning or periodontal treatment. No payment for fillings. No payment for partials and dentures.

4 CMOs Amerigroup Scion Regular Medicaid HP Peach State DentaQuest * WellCare DentaQuest On November 1 st, 2012, Peach State will be administered by Avesis. Dental offices will use four different web sites to verify eligibility, check service history, and print payment information. Dental providers will need to be credentialed by four different companies.

5 Fee Reductions Amerigroup cut reimbursement rates by 15% (rural counties) and 25 % (urban counties) in July Peach State made similar 15% and 25% cuts in June WellCare cut reimbursements in the North and Atlanta regions in October 2009 by % depending on the code (the most severe cuts were to the highest utilized codes). Source: Georgia Dental Association Reimbursement rates for x-rays provided on same day of service have also been reduced to the full mouth series fee. Each region has a different fee and it ranges from $ $ HP has not reduced fees.

6 Fee Reductions ADA Code Comprehensiv e Exam D0150 Doral Wellcare New Rate North Region % Reduction New Rate Atlanta Region % Reduction $39.33 $ % $ % Amalgam, one surface D0140 $60.03 $ % $ % Composite, one surface D2391 $88.80 $ % $ % Stainless Steel Crown D2930 $ $ % $ %

7 Fee Reductions Rural Areas ADA Code Wellcare/HP Amerigroup/ Peach State Limited exam (problem Focused) D0140 $38.29 $ % Sealant D1351 Extraction D7140 $27.94 $ % $64.17 $ % Amalgam, two surface D2150 $77.62 $ % % Reduction

8 South Central Health District *Three counties do not have a dentist (Johnson, Montgomery, and Wheeler). *The nearest Oral Surgeon who accepts Medicaid is.. in Macon. This is at least an hour drive. *Pediatric dentists who accept Peach State are in Tifton, Savannah, and Macon. *Georgia Health Sciences University accepts our referrals but is a two hour drive.

9 Safety Net Dental Clinic Clinic provides emergency treatment, routine dental treatment, regular six month recall visits, sealants and fluoride varnish for children. Our clinic is only public health dental clinic in our ten-county health district. We have limited Peach State providers in our area. Some of our parents have no insurance or Medicaid. We charge sliding scale fees based on parents income like Health Department and no child is refused service if parent cannot pay. Many of our kids have too many broken appointments at other dentists and they will not give child another appointment.

10 Broken Appointments We added a part-time dentist at our clinic this year. We need to generate enough Medicaid funds to pay for two dental assistants and a dentist. Broken appointments are a persistent problem. From 1/1/12 until 6/30/12, our clinic has had 458 broken appointments. Average 76.3 no shows per month. Broken appointments are a budget buster. Increasing the number of providers does not always increase access because parents do not bring their children for scheduled appointments.

11 School System Oral Health Screening Survey In the fall of 2011, 1674 students from a school system were provided a dental screening, hearing screening, and vision screening. Results of dental screening: 77% or 1293 children had no visible cavities. 17% or 291 children had probable cavities. 6% or 90 children either had a toothache or an abscessed tooth and were in need of emergency dental care. Project helped school nurses identify children in need of immediate dental care. Parents were contacted and attempts were made to help families find dental care for their child.

12 Dental Decay

13 Brush, Floss, Snack Healthy and Visit your Dentist twice a year. Debra Bradfield Smith, D.M.D. District Dental Director South Central Health District 702 Academy Avenue, Suite A Dublin, Georgia dbsmith@dhr.state.ga.us

14 Questions or Comments