Medicaid-FQHC Dental Policy Workshop Meeting Courtyard Marriott, Chevy Chase, Maryland September 18, 2017
Welcome and Introductions Sarah Finne, DMD MSDA President NH Medicaid Dental Director
Ground Rules Please honor time limits Please silence your mobile phones Don t be afraid to ask questions Don t assume everybody knows dental or Medicaid acronyms Please ask questions through the facilitator
Background and Charge 1) Identify policy gaps that may have contributed to recent FQHC audit issues; 2) identify areas/opportunities for improvement; and 3) develop recommendations for consideration by CMS; HRSA; and state Medicaid and CHIP Programs to prevent future FQHC dental provider related audits and overpayment issues.
Medicaid-FQHC Dental Policy Workgroup Other FQHC Stakeholders?
Overview Federal Authority and Guidance HRSA Rene Joskow, DDS HRSA Ethan Joselow CMS, CMCS Lynn Mouden, DDS CMS, CPI Horace Dozier
Guiding Federal Legislation Section 330 Public Health Service Act Health Center Program Statute: Section 330 of the Public Health Service Act (42 U.S.C. 254b) Social Security Act: 1936- Medicaid Integrity Program https://www.ssa.gov/op_home/ssact/title19/1936.htm Section 1905(l)(2)(B) of the Social Security Act. https://www.ssa.gov/op_home/ssact/title19/1905.htm Patient Protection And Affordable Care Act of 2010 http://housedocs.house.gov/energycommerce/ppacacon.pdf Health Care and Education Reconciliation Act 2010 https://www.congress.gov/bill/111th-congress/house-bill/4872/text CHIPRA 2009 https://www.gpo.gov/fdsys/pkg/plaw-111publ3/pdf/plaw-111publ3.pdf Improper Payments and Information Act 2002 https://www.congress.gov/bill/107th-congress/house-bill/4878/text Improper Payments Elimination and Recovery act 2010 https://paymentaccuracy.gov/pdf/pl_111-204.pdf
Guiding Federal Regulation Centers for Medicare & Medicaid Services Center for Program Integrity Deputy Director Horace Dozier
Overview of Program Integrity Audits Medicaid Integrity Contractors (MIC) Payment Error Rate Measurement (PERM) Recovery Audit Contractors (RAC) Deputy Director Horace Dozier CMS, CPI
Guiding State Legislation, Regulation; and Policy State Plans and State Medicaid Policies for Dental Providers [Provider Manuals] State polices and regulations are state specific State Plans must include benefits & payment structure Provider Manuals: Generally developed broadly for private practice settings and FFS payment models Rarely incorporate specificity for FQHC dental PPS models Lack specificity around bundling/unbundling State Examples
Guiding State Legislation, Regulation; and Policy State Plans Dental Provider Manuals State Examples: California Brian Kennedy, DDS Rhode Island Joan Pillsbury New Hampshire Sarah Finne, DMD South Dakota Nance Orsbon
Discussion Emerging Issues Quality in Healthcare Standard of Care FQHC Audits Mary Foley, MPH
Quality in Healthcare Unwarranted Variation in Healthcare 1967 John Wennberg Study exploring Medicare data to determine how well hospitals and doctors were performing. Utilization data from Vermont, Maine & Iowa: Hysterectomy by age 70 20% vs. 70% Prostatectomy by age 85 15% vs. 60% Tonsillectomy 8% vs. 70% Significant variability in delivery of services Could find no scientific research on outcomes of care to demonstrate that one population was better off than the other Wennberg J, Gittelsohn A. Small area variations in health care delivery. Science 1973 Dec 14;182(117):1102-8. PMID 4750608 Slide courtesy of Dr. Rob Compton https://www.ncbi.nlm.nih.gov/pmc/articles/pmc1124450/ 13
Standard of Care The first thing to know is that standard of care is a legal term. It is not a medical term. That means that it is primarily lawyers, not doctors, who use the term. http://glidewelldental.com/education/inclusive- dental-implant-magazine/volume-7-issue- 3/standard-legal-implant-dentistry
Standard of care in dentistry: Where did it come from?
Recent FQHC Medicaid Audits Allen Finkelstein, DDS and Timothy Martinez, DMD Process Auditors Findings Excessive Visits Insufficient documentation Non-covered service Non-eligible provider Not medically necessary Violations
FQHC Audits: State & Partner Perspectives Iowa Nancy Adrianse, BSDH California Huong Lee, DDS California Ariane Terlet, DDS California Angie Melton
FQHC Audits: Provider Perspectives Sid Whitman, DDS ADA Irene Hilton, DDS CA FQHC Bruce Hebets, CEO Borrego FQHC
FQHC Audits: Medicaid MCO Perspective Nance Orson Delta Dental of South Dakota Michael Exler, DDS Avesis Dental
Articulating the Problem: Policy Gaps State Plans FQHC Dental Provider Manuals Rate Setting & Fee Schedules Marty Dellapenna- MSDA
California- DHCS
California: Medicaid Dental Policy in Dental Provider Manual
Dental Provider Manual Example of Bundling Policy * Excessive Visit
NH Legislation PART He-W 546 EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT SERVICES http://www.gencourt.state.nh.us/rules/filinghistory/sourcehe-w.html
NH State Plan Regarding Dental Benefits
NH State Plan Regarding Dental Payments: Refers to Fee Schedule
NH Dental Provider Manual Example of Payment Restrictions & Specificity
NH Dental Provider Manual Example of Bundling Restrictions
Vermont State Plan Regarding Dental Service Payment 10. Dental Services Payment is made at the lower of the actual charge or the Medicaid rate. The agency s rates were set as of 1/1/14 and are effective for services on or after that date. All rates are published at www.dvha.vermont.gov/for-providers. Except as otherwise noted in the plan, State developed fee schedule rates are the same for both governmental and private.
Vermont State Plan: RE: FQHC
RI FQHC Dental Provider Manual February 2017 Scope of Services The Medicaid Program provides payment only for services that are included in the scope of services described in the DHS Manual at Sections 033.20; 0348; 0398 and 0399 of the DHS manual for the RIteCare Program, or under a waiver program at Section 0398; or for recipients under the age of 21 pursuant to the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, for additional services that are not included in the above sections, and that are definable under Section 1905(a) and 1905(a)(2)(B)(C) of the federal Social Security Act. Specific details of services reimbursable and limitations thereon are contained in the Medicaid Program Provider Reference Guides, the Rhode Island Title XIX State Plan, Section 1115 and Section 1915 Waiver requests, and the RIte Care Program Managed Care Plan and Contracts. Payment is not made for services other than those described herein.
RI FQHC Dental Provider Manual Examples of Encounter-Payment Limitations
Areas/Opportunities for Improvement Recommendations for: CMS, HRSA, and State Medicaid Agencies American Dental Association American Academy of Pediatric Dentistry Mary Foley
Developing Solutions Next Steps for the MSDA Medicaid-FQHC Dental Policy Workgroup Mary Foley
ADA Clinical Practice Guidelines Guidelines Center for Evidence Based Dentistry http://ebd.ada.org/en/evidence/guidelines Evidence-based clinical practice guideline for the use of pit-and-fissure sealants (2016) http://ebd.ada.org/en/evidence/guidelines/pit-and-fissure-sealants Professionally-applied and Prescription-strength, Home-use Topical Fluoride Agents for Caries Prevention Clinical Practice Guideline (2013) http://ebd.ada.org/en/evidence/guidelines/topical-fluoride
AAPD Policies and Clinical Practice Guidelines Policies and Guidelines http://www.aapd.org/policies/ Periodicity Schedules http://www.aapd.org/media/policies_guidelines/g_periodicity7.pdf States That Use AAPD Recommended Dental Periodicity Schedule Alaska; Arkansas; California; Colorado; Connecticut; Delaware; District of Columbia; Florida; Georgia; Hawaii; Idaho; Illinois; Indiana; Iowa; Kansas; Maryland; Massachusetts; Michigan; Minnesota; Mississippi; Nebraska; Nevada; New Hampshire; New York; North Dakota; Oregon; Pennsylvania; South Dakota; Tennessee; Texas; Utah; Virginia; West Virginia; Wisconsin
Contact Information Medicaid Medicare CHIP Services Dental Association 4411 Connecticut Ave. NW Unit 401 Washington DC 2000 Mary Foley, RDH, MPH mfoley@medicaiddental.org Marty Dellapenna, RDH, MEd mdellapenna@medicaiddental.org