1 Pediatric Restorative Benefits: Potential for Fraud & Abuse Part 2 The Medicaid-Commercial Spectrum, Media Reports of Abuse, U.S. Senate Study, Quest for the Facts and a Plan of Action Craig Kasten Wednesday September 17, 2014 1:30pm
2 Introduction & Review of Part 1 Insights learned over the past two decades
A B O U T Craig Kasten: Industry Founder 3 2009 1994 Founder: Scion Dental Founder: Doral Dental Sole Focus = Medicaid Beneficiaries Combined, these two companies today arrange for the delivery of dental benefits to over 25 million children nationwide 1993 Founder: Wonderbox Technologies Dental & Vision Cloud Computing Services Headquarters in Wisconsin
4 Commercial Dental vs. Medicaid Dental A tale of two cities
Patient Eligibility Verification 5 Medicaid Dental Commercial Dental Always verified before patient appointments Rarely verified before patient appointments 50% of member calls are find a provider
Benefit Plan Design 6 Medicaid Dental Commercial Dental Plan designs seldom change No deductibles No coinsurance or copayments No annual maximums Plan designs often change Deductibles Coinsurance or copayments Annual maximums
Patient Scheduling 7 Medicaid Dental Commercial Dental Double booking practiced 50% of appointments missed Double booking is not an acceptable practice
Dentist Participation 8 Medicaid Dental Commercial Dental ~15% of all dentists participate (varies by state based on fees) ~100% of all dentists see commercial patients
Patient Age 9 Medicaid Dental Commercial Dental ~100% of patients age 21 and under (limited adult coverage varies by state) ~25% of patients age 21 and under
Reimbursement Variance by State 10 Medicaid Dental Commercial Dental Fees and aggregate per capita spending vary dramatically by state Range of $8 pmpm to $30 pmpm Relatively consistent spending across regions
Patient Access to Services 11 Medicaid Dental Commercial Dental Top priority Complex reporting requirements with significant financial penalties for failure to attain targeted access levels Seldom (never) mentioned as a top concern with financial benefit accruing to insurer or employer from lower service utilization levels
Dental Plan Funding & Billing 12 Medicaid Dental Commercial Dental 100% government funded (split between Federal and State) No client billing requirements No broker commissions 100% funded by private sector sources, extensive effort to bill, and reconcile payments Broker commissions common
M E D I C A I D V S. C O M M E R C I A L Other Differentiating Patient Attributes 13 Transient residency Waiting room requirements Language barriers Oral hygiene training Patient transportation options Urban/Rural concentration
M E D I C A I D V S. C O M M E R C I A L Common Result 14 Commercial dental insurers fail miserably when attempting to manage Medicaid benefits due to: 1. Inadequate systems to address Medicaid priorities, manage call volumes and address unique reporting requirements 2. Inappropriate business model
15 Pediatric Overtreatment: Widely Reported and Studied A vulnerable population with no out of pocket charges to constrain potential patient abuse
R E P O R T E D & S T U D I E D News and Media Reports 16
R E P O R T E D & S T U D I E D News and Media Reports 17
R E P O R T E D & S T U D I E D Senate Investigation 18 Church Street Health Management 70 Small Smiles dental clinics in 22 states and the District of Columbia NCDR 130 Kool Smiles clinics in 15 states and the District of Columbia ReachOut Healthcare America Operates mobile school-based clinics in several states Heartland Dental Care 300 clinics in 18 states Aspen Dental Management 300 Aspen Dental clinics in 22 states
R E P O R T E D & S T U D I E D Senate Investigation 19 Recommendations 1. Exclude these two organizations from Medicaid participation 2. Have States enforce laws to prohibit corporate practice of dentistry 3. Consider the licensure of mid-level providers
R E P O R T E D & S T U D I E D Senate Investigation 20 ADA Response: Such conduct is inexcusable, and should be prosecuted vigorously. However, equally disturbing is the broad brush that implicates a whole class of practice models rather than focusing on the actual offenders.
R E P O R T E D & S T U D I E D Intriguing Senate Panel Question 21 If the fees are so low, why are there millionaire dentists in Medicaid?
22 Recent Updates
R E C E N T U P D A T E S Medicaid Expansion - 133% of Fed Poverty Level 23 Table 1: Medicaid and CHIP: May and June 2014 Preliminary Monthly Enrollment
24 Era of Accountability: RAC Audits Section 6411 of the Patient Protection and Affordable Care Act (ACA) directs states to establish programs in which they will contract with one or more Recovery Audit Contractors (RAC), to reduce improper payments.
R A C A U D I T S How does it work? 25 Each RAC contractor uses its own proprietary methodologies developed in compliance with CMS rules and regulations. RACs will report potential fraud to CMS and potential quality issues to the state or territory Quality Improvement Organization (QIO).
26 Let s Dig a Bit Further: Proprietary Research What do the facts indicate? Aggregate per capita cost by age Extreme patient cases To those who should be concerned.
P R O P R I E T A R Y R E S E A R C H Aggregate Market Data 27 All Regions
P R O P R I E T A R Y R E S E A R C H Aggregate Market Data (continued) 28 All Regions
P R O P R I E T A R Y R E S E A R C H Eruption/Exfoliation 29
P R O P R I E T A R Y R E S E A R C H Eruption/Exfoliation (continued) 30
31 Proprietary Research: Extreme Patient Cases Pulled from internal database
P R O P R I E T A R Y R E S E A R C H Extreme Patient Cases 32 Patient A: 3 years old 18 crowns before age 4 9 teeth crowned more than once $7,000 in restorative services before age 4
P R O P R I E T A R Y R E S E A R C H Extreme Patient Cases (continued) 33 Patient B: 1 years old 16 teeth extracted during one visit Performed in a pediatric office No general anesthesia Remaining teeth extracted within 5 months All teeth removed by age 2 $3,900 in one dental visit
P R O P R I E T A R Y R E S E A R C H Extreme Patient Cases (continued) 34 Patient C: 1 years old 26 procedures on same day, including: 10 Extractions 8 Crowns 1 Therapeutic Pulpotomy $4,000 in one pediatric dental visit
P R O P R I E T A R Y R E S E A R C H Extreme Patient Cases (continued) 35 Patient D: 5 years old All services received on same day 19 Crowns 10 Pulp caps 1 Pulpal therapy 3 Pulpotomies 1 Extraction $6,700 in dental services in one visit
P R O P R I E T A R Y R E S E A R C H Recent Extreme Patient Cases 36 Patient A: 2 years old All services received on same day 16 Root Canals 16 Crowns No anesthesia billed $7,700 in dental services in one visit
P R O P R I E T A R Y R E S E A R C H Recent Extreme Patient Cases (continued) 37 Patient B: 2 years old All services received on same day 16 Extractions Remaining 4 teeth received both a Pulpotomy and SS Crown Remaining teeth: not upper/lower corresponding $3,600 in dental services in one visit
P R O P R I E T A R Y R E S E A R C H Recent Extreme Patient Cases (continued) 38 Patient C: 5 years old All services received on same day All 20 teeth received a Pulpotomy and a Crown 4.5 hours of general anesthesia $7,500 in dental services in one visit CONFIDENTIAL & PROPRIETARY 2014 Scion Dental, Inc.
P R O P R I E T A R Y R E S E A R C H Recent Extreme Patient Cases (continued) 39 Patient D: 5 years old All services received on same day 19 Crowns 10 Pulp caps 1 Pulpal therapy 3 Pulpotomies 1 Extraction $6,700 in dental services in one visit
P R O P R I E T A R Y R E S E A R C H Recent Extreme Patient Cases (continued) 40 Patient E: 3 years old All services received on same day 20 Surgical Extractions 4 Alveoloplasty 10 Other Surgical Procedures $10,600 in dental services in one visit
To those who should be concerned 41
Fraud and/or abuse of young patients enrolled in Medicaid is a continuing problem that needs to be addressed. 42 Many dentists & clinics in Medicaid do a great job
43 Education On-line Provider Profiling - Early Identification - Age Banded Industry Collaboration Institute for Research & Policy Formation ADA Technology-Aided Solutions New Outlier Sanction Program New Claim Edits based on Tooth Properties Eruption Date Variance from DOS Exfoliation Date Variance from DOS Mobile phone patient outreach
P R O V I D E R E D U C A T I O N Age Banded Real Time Provider Profiling 44
P R O V I D E R W E B P O R T A L Provider Education 45 Provider Web Portal Custom reports allow provider to compare utilization vs. peers
P R O P R I E T A R Y Sanction Program Enterprise System Statistical Analysis/ Provider Profiling Hotline Tips 46 Client Discretion Client Notification Provider Education Letter No Severe Allegation Yes Yes Revised Behavior No Able to Chart Audit Clinical Review (Chart Audit) Yes No No Aberrant Results in Chart Audit Yes No Action Required Additional Authorization or Documentation Requirements** Alternative Reimbursement Methods** Suspension or Termination** ** Dependent on severity of aberrant behavior
P R O P R I E T A R Y Sanction Program- In Effect 47 Provider A General Dentist Overutilization of CDT code D4341 Initial Intervention: Require authorization Behavior revised After sanction, CDT code D4355 is overutilized Future intervention: Require authorization on all periodontic codes
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Industry Collaboration 49 Institute for Research & Policy Formation ADA NADP
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