NORTH CAROLINA MEDICAID DENTAL PROGRAM UPDATE

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NORTH CAROLINA MEDICAID DENTAL PROGRAM UPDATE

• July 16, 2008
• 2008 Statewide Oral Health Conference

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Objectives of Presentation

• Discussion of budgetary trends including latest
  strategies for reimbursement rate increases
• Discussion of policy initiatives recently
  implemented, in progress and planned for the
  future
• Discussion of access to care measurements
  methodologies, recent DMA NC county data and
  trends in data
• Brief introduction to documentation for the
  purposes of payment by third party payers
  Federal OIGs Report on Improper Payments for
  Medicaid Pediatric Dental Services

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MEDICAID DENTAL EXPENDITURES

• Increases in expenditures each year from SFY 1990
  SFY 2007 (16.8 million to 240 million)
• SFY 2008 targeting total expenditures at approx.
  270 million after 11 months of the SFY. Over SFY
  2007, SFY 2008 expenditures up almost 11 and
  total number of recips receiving services up 8
• Dental Program share of Total Medicaid
  Expenditures has grown from 1.2 in SFY 1990 to
  over 2.5 in SFY 2007
• In terms of growth in expenditures from SFY
  2003 to SFY 2007 dental expenditures ranked
  second at 86 over the five year period ahead
  of physician services, inpatient hospital
  services and mental health clinic services. Only
  trails non-physician practitioner services-
  includes COMMUNITY SUPPORT!

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MEDICAID SERVICES EXPENDITURES SFY 2006
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Growth in Dental Program from SFY 1990 - SFY
2006( of Total Medicaid Program Expenditures)
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Total Dental ExpendituresSFY 1990 SFY 2007
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Top Ten Procedures(ranked by total cost to
Medicaid) Reimbursement Rate Comparisons
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Reimbursement Rates

• Overhead expenses for an average dental office
  are approximately 65 of collections --
  procedures reimbursed below 65 of NDAS benchmark
  means provider loses money
• Adult services (denture, oral surgery, endodontic
  and periodontal) still lag behind -- many of
  these procedures are at or near the current floor
  below 50 of the 2007 NDAS median
• Increasing these rates should attract more
  specialists (oral surgeons, orthodontists,
  endodontists and periodontists) to enroll in
  Medicaid
• Many preventive and diagnostic services are
  reimbursed at higher rates well above 60 of NDAS
  benchmark median increased utilization of these
  services should lead to cost savings to the
  Medicaid program in the future

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Reimbursement Rates

• Top ten procedures in total cost to NC Medicaid
  average at 64 of 2007 NDAS (National Dental
  Advisory Service) benchmark
• Top ten procedures in total cost account for
  roughly 48 of overall dental expenditures
• 2003 lawsuit settlement increasing reimbursement
  for 37 procedural codes has improved
  reimbursement rates for childrens services
• Weighted average for all 200 covered services is
  approx. 62

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Reimbursement Rates

• More needs to be done to increase reimbursement
  rates with a target goal of 75-80 of NDAS
  median, but progress has been made over the last
  five years
• Increases in reimbursement rates to reflect
  prevailing market rates should be sustained by
  annual rate increases to match the Dental CPI of
  4.9 per year.
• Increasing rates will create a Field of Dreams
  effect Build it and maintain it and they will
  come and remain active provider enrollment
  will increase
• Examples Indiana (1998), South Carolina (2000),
  Alabama (2000), Tennessee (2002), North Carolina
  (2003), Virginia (2005)

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Strategies to Increase Reimbursement Rates

• The NCGA has included a special provision in the
  State Budget to increase Medicaid dental
  reimbursement rates 5 million in state approps
  recurring funding over the next two SFYs.
• With FMAP and county share this means a little
  less than 15 million for rate increases or
  between 5-6 of projected SFY 2008 dental budget
• Smaller increases make it harder to decide where
  the funding should be applied
• Some of the funding will be used to cover
  increases in inflation, consumption and increased
  numbers of recipients receiving services due to
  rate increases

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Strategies to Increase Reimbursement Rates

• Increase the floor from 48 of NDAS median
• Pros will increase rates for procedures that are
  furthest behind market based benchmarks (UCR)
  oral surgery, removable pros, endo, perio, etc.
  mostly adult services at or near the floor of
  48 NDAS.
• Cons
• Will not address lawsuit settlement codes
  (childrens services) no increase in these
  codes since 2003
• Will result in criticism from some circles in the
  provider community

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Strategies to Increase Reimbursement Rates

• Targeted rate increases
• Pros allows increases in the rates for codes
  that program staff deem most worthy of increase
  based on utilization and other factors
• Cons
• May not raise the floor for many services that
  lag far behind market based benchmarks
• Will result in criticism from some circles in the
  provider community

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ConclusionsStrategies to Increase Reimbursement
Rates

• You cant please all the people (providers) all
  the time
• DMA has employed forms of both strategies in the
  last three rate increases since 9/2006.
• Zigging and zagging to address needs with
  limited funding
• Kudos to NCGA for including rate increases in the
  budget and to organized dentistry for recent
  successful lobbying efforts.
• Please, sir (and madam), can we have more?
• We have come a long way since the lawsuit
  settlement in 2003.

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Adoption of D0145

• Why?
• Promote the concept of the dental home by age 1
• Encourage dentists to treat Medicaid preschool
  children and increase access to oral health care
  for this group of recipients
• Link the oral evaluation code to the safest and
  most effective preventive technique to reduce
  early childhood caries (ECC) fluoride varnish

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Adoption of D0145

• What is it?
• D0145 oral evaluation for a patient under three
  years of age and counseling with primary
  caregiver
• Preferably within first 6 months of the eruption
  of the first primary tooth
• Includes
• Recording the oral and physical health history
• Evaluation of caries susceptibility (assess risk
  for ECC)
• Development of an appropriate preventive oral
  health regimen
• Communication with and counseling of the childs
  parent(s)/guardian and/or primary caregiver

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Adoption of D0145

• Who can render the service?
• Dentist must complete the diagnostic oral
  evaluation and subsequent treatment planning
• RDHs, CDAs can complete delegable tasks such as
  recording of oral and physical health history,
  development of an appropriate preventive oral
  health regimen and portions of the evaluation of
  caries susceptibility.

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Adoption of D0145 Claims/Billing Instructions

• D0145 must be provided on the same date of
  service and billed in conjunction with D1206
  (topical fluoride varnish) therapeutic
  application for moderate to high caries risk
  patients to receive payment for any claim
  including D0145.
• Why? evidence based research indicates that FV
  is the most effective and safest preventive
  technique in the battle against ECC

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Adoption of D0145 Claims/Billing Instructions

• Other dental services (except other diagnostic
  and fluoride procedures) can be provided on the
  same date of service as the D0145 and D1206
  diagnostic/preventive oral health service
  package.
• At age 3 and older, only D0120 is allowed for
  periodic visits.

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Claims/Billing Instructions

• Flexibility allowed
• If providers do not wish to apply topical FV
  (D1206) to a patient under 3 years of age at a
  periodic visit, they may still use procedural
  code D0120 to report and receive reimbursement
  for the periodic oral evaluation rendered on that
  date of service.
• Any of the three diagnostic codes (D0120, D0145
  or D0150) can be billed for the patients first
  visit. However, D0145 must be provided in
  conjunction with D1206 -- topical FV to receive
  reimbursement for any claim with D0145 .
• For follow-up visits D0120 or D0145 can be
  rendered every 6 calendar months until age 3.
  (Again, D0145 must be provided with D1206
  topical FV)

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(No Transcript)
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SamplePeriodicity Schedule for Diagnostic and
Preventive Services for Preschool Recipients
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Policy InitiativesIn Progress

• D2393 resin based composite -- three surfaces,
  posterior will eliminate policy limit and allow
  procedure on primary molars. Policy limit remains
  in effect on D2394.
• Considering changing the frequency interval of
  D0145 oral evaluation of a patient under three
  years of age and D1206 topical fluoride varnish
  application to allow as often as every 4 months
  for preschool recipients who are identified
  through caries risk assessment as susceptible to
  ECC.

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Policy InitiativesFuture Plans(That Vision
Thing)

• Improve access for special care patients
• Examine other models
• Enhanced reimbursement Florida, South Carolina
• Adopt D9920 behavior management, by report
  Arizona, New Mexico
• Training requirements for providers pediatric
  residency, GPR, geriatric fellowship, special
  care fellowship, AHEC or UNC SOD course limited
  to qualified providers
• No prior approval for D9920, limitations of
  present MMIS to prevent overutilization of code
  how do we link recipient medical diagnosis to
  eligibility to receive D9920 service?

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Growth in Number of Billing Providers
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Growth in Number of Billing Providers
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Enrolled Providers -- SFY 2007

• 1795 enrolled billing providers with at least one
  paid claim
• billing providers receive payment
• Approx. 2000 enrolled attending providers with at
  least one paid claim
• attending providers render treatment
• 3939 active licensed dentists in NC at end of CY
  2007
• gt50 of active licensed dentists in provider
  network
• implications more dentists participate in
  Medicaid than typically reported in the media
  does not sell papers nor does it necessarily help
  those who advocate for higher reimbursement
• those greedy dentists may not be as bad as
  reported

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Access to Dental Care All Recipients
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Access to Dental Care lt 21
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Access Measurements SFY 2007 --County Specific
Snapshots

• DMA QEHO has calculated dental access
  measurements for children lt 21 and adults gt21
  for each NC county
• Please see this data along with other interesting
  demographic and health care data for each county
  at www.dhhs.state.nc.us/dma/countyreports/county
  reports.html
• Why? to enable policymakers and other
  stakeholders a chance to examine and better
  understand Medicaid data on the local level

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Access Measurements SFY 2007 --County Specific
Snapshots

• Methodology for dental access measurements same
  as current CMS recommendations on the CMS 416
  (line 12a/line 1)
• Numerator of Medicaid eligibles receiving any
  dental procedure (CDT code) for the reporting
  period
• Implications for NC this includes preschool
  kids receiving IMB services from PCPs and
  extenders
• Controversial among some pediatric oral health
  policy experts Federal EPSDT regs define dental
  services as those provided by a dentist or under
  the supervision of a dentist
• Are physicians permitted by state law to practice
  dentistry? YES!
• Still, there are naysayers who believe that PCPs
  and extenders are not an effective means of
  providing diagnostic and preventive procedures
  and only fulfilling one piece of the EPSDT regs
  requirement for comprehensive dental services
  fragmented care should not be counted on line
  12a

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Access Measurements SFY 2007 --County Specific
Snapshots

• Denominator any Medicaid recipient eligible for
  Medicaid dental services during the reporting
  year
• Implications any Medicaid recipient eligible
  for even one month is included in the access
  measurement for the year no requirement for
  continuous enrollment
• Differs from other accepted access measures like
  HEDIS ADV which require continuous enrollment
  (HEDIS 11 out of 12 months) see handout for
  statewide HEDIS ADV results for CY 2006
• Lack of continuous enrollment requirement has
  dramatic effect on Medicaid access measurements
  because of the transient nature of Medicaid
  eligibility ex. in NC in SFY 2006 approx. 1.6
  million recips eligible at any time during the
  year, but average monthly eligibility was 1.2
  million.

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Access Measurements SFY 2007 --County Specific
SnapshotsTrends

• Data is based on recipient county of residence,
  not on where care is obtained
• Access for adults poorer than for children
• Some NE and SW rural and remote counties have
  access measures well below state average for both
  age groups Dare, Camden, Pasquotank, Swain,
  Currituck, Perquimans, Bertie and Jackson
• Some urban counties with large numbers of active
  licensed dentists, enrolled Medicaid providers
  and Medicaid recips are a little below the state
  average for children Cumberland, Mecklenburg,
  New Hanover, Wake.
• The ratio of actively participating
  dentistsMedicaid recips is low
• Some urban counties with the same elements are
  significantly above the state average for
  children Buncombe, Durham, Forsyth, Guilford

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Access Measurements SFY 2007 --County Specific
SnapshotsTrends/Analysis

• Some of the counties with access well above the
  state average for children are not urban
  Wilkes, Carteret, Craven, Franklin, Hyde,
  Montgomery, Moore, Polk, Wayne, Yancey
• Analysis What does it all mean?
• Not entirely accurate to state that urban access
  is better than rural for the underserved when
  referring strictly to Medicaid recipients
• Still need to address access issues in remote NE
  and SW counties
• Adult access is improving but slowly strategies
  to improve?
• More training and incentives to providers to
  increased access for special care patients
• Key ingredients to success not entirely clear
  and more detailed analysis is necessary
• Hypothesis takes good teamwork between active
  public and private providers to achieve success
  only limited success without both sides pulling
  their weight

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Documentation for Payment Purposes

• Federal DHHS OIGs Report on Improper Payments
  for Medicaid Pediatric Dental Services
  www.oig.hhs.gov/oei/reports/oei-04-04-00210.pdf
  Released September 2007
• NC one of five states examined for CY 2003
  payments
• Overall results of study 31 of Medicaid
  pediatric dental payments were found to be in
  error services provided in error estimated to
  be about 155 million, of that an estimated 96
  million came from the Feds
• 24 documentation errors that resulted in
  reviewers being unable to determine that services
  were medically necessary and/or billed
  appropriately
• 7 did not meet billing requirements
• 2 were medically unnecessary procedures
• Exceeds 31 because some services had more than
  one error

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Documentation for Payment Purposes

• Examples of documentation errors
• 6 -- undocumented errors no record of the
  service in the patients chart or service was
  unsubstantiated by records submitted
• 9 -- insufficient documentation to determine
  correct billing
• Restoration performed with no identification of
  surfaces restored
• Surgical removal of impacted tooth with no
  documentation demonstrating type of removal
• 13 -- insufficient documentation to determine
  medical necessity
• SSC provided documented in record, no
  supporting radiograph
• Procedure supported by an inconclusive or
  undiagnostic radiograph

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Documentation for Payment Purposes

• 7 billing errors incorrect procedure codes,
  services that were not billable because they
  violated policy or statute, incorrect number of
  units, unbundled services
• Upcoding providing a two surface restoration
  and billing for a four surface restoration
• Downcoding billing a non-surgical extraction
  when providing a surgical removal of a tooth
• Not billable service two orthodontic
  adjustments in the same month violating policy
  limit on once per month

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Documentation for Payment Purposes

• Criticism of OIGs study abounds
• OIG substantially overstated error rates -- truly
  improper payment rates are probably about the
  same in Medicaid as in commercial insurance.
• The medical necessity standard is a difficult
  standard to apply to dental records because
  dentistry, unlike medicine, does not employ ICD9
  diagnostic codes no standardization for billing
  purposes. Diagnoses can vary depending on the
  clinician reviewing the patient records and
  radiographs.
• Nearly 5 of the claims categorized as
  undocumented were records that were not
  reviewed because they were not provided by the
  subject dentists most studies would eliminate
  these from consideration not the OIG!

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Documentation for Payment Purposes

• Too strict in terms of requirements for
  documentation
• Taking a diagnostic radiograph prior to an SSC
  may be very difficult on a preschooler according
  to the OIGs study guidelines documenting
  necessity based on clinical findings is not
  enough
• Too strict in terms of what is considered an
  error
• transcription errors are counted ex. DOS in
  patient record does not match DOS on claim form

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Documentation for Payment Purposes

• Lessons Learned
• CMS and States need to do more outreach to
  educate providers about the need for better
  documentation and to ensure compliance with
  policies and State and Federal statutes and regs
• CMS and States need to refine prepayment MMIS
  audits and edits and develop better post-payment
  review techniques that ensure appropriate
  documentation is occurring in the provider
  community
• Providers should take the initiative to seek
  training and guidance from the State Medicaid
  agencies these resources are available in NC
  from both DMA and EDS.

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Division of Medical AssistanceNC MedicaidDental
Program

• www.ncdhhs.gov/dma/dental.htm
• Mark W. Casey, DDS, MPH
• Dental Director
• Mark.Casey_at_ncmail.net
• 919-855-4280