Pediatric Restorative Benefits: Potential for Fraud & Abuse · PDF filePediatric Restorative...
Transcript of Pediatric Restorative Benefits: Potential for Fraud & Abuse · PDF filePediatric Restorative...
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Craig Kasten Wednesday September 17, 2014 1:30pm
Part 2
The Medicaid-Commercial Spectrum, Media Reports of Abuse, U.S.
Senate Study, Quest for the Facts and a Plan of Action
Pediatric Restorative Benefits:
Potential for Fraud & Abuse
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Insights learned over the past two decades
Introduction & Review of Part 1
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Sole Focus = Medicaid Beneficiaries
Craig Kasten: Industry Founder A B O U T
Founder: Wonderbox Technologies 1993
Founder: Doral Dental 1994
Founder: Scion Dental 2009
Dental & Vision Cloud Computing Services Headquarters in Wisconsin
Combined, these two companies today arrange for the delivery of dental benefits to over 25 million children nationwide
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A tale of two cities
Commercial Dental vs.
Medicaid Dental
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Medicaid Dental Commercial Dental
Patient Eligibility Verification
Always verified before patient
appointments
50% of member calls are “find
a provider”
Rarely verified before patient
appointments
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Medicaid Dental Commercial Dental
Benefit Plan Design
Plan designs seldom change
No deductibles
No coinsurance or copayments
No annual maximums
Plan designs often change
Deductibles
Coinsurance or copayments
Annual maximums
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Medicaid Dental Commercial Dental
Patient Scheduling
Double booking practiced…
50% of appointments missed
Double booking is not an
acceptable practice
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Medicaid Dental Commercial Dental
Dentist Participation
~15% of all dentists participate
(varies by state based on fees)
~100% of all dentists see
commercial patients
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Medicaid Dental Commercial Dental
Patient Age
~100% of patients age 21 and
under (limited adult coverage
varies by state)
~25% of patients age 21 and
under
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Medicaid Dental Commercial Dental
Reimbursement Variance by State
Fees and aggregate per capita
spending vary dramatically by
state
Range of $8 pmpm to $30
pmpm
Relatively consistent spending
across regions
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Medicaid Dental Commercial Dental
Patient Access to Services
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 © 2014 Scion Dental, Inc. CONFIDENTIAL & PROPRIETARY
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Medicaid Dental Commercial Dental
Dental Plan Funding & Billing
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
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Other Differentiating Patient Attributes M E D I C A I D V S . C O M M E R C I A L
Transient residency
Language barriers
Patient transportation
options
Waiting room requirements
Oral hygiene training
Urban/Rural concentration
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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
Common Result M E D I C A I D V S . C O M M E R C I A L
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A vulnerable population with no out of pocket charges to constrain potential patient abuse
Pediatric Overtreatment: Widely
Reported and Studied
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News and Media Reports R E P O R T E D & S T U D I E D
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News and Media Reports R E P O R T E D & S T U D I E D
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Senate Investigation R E P O R T E D & S T U D I E D
Church Street Health Management
70 Small Smiles dental clinics in 22 states and the District of Columbia
130 Kool Smiles clinics in 15 states and the District of Columbia
Operates mobile school-based clinics in several states
300 clinics in 18 states
300 Aspen Dental clinics in 22 states
NCDR
ReachOut Healthcare America
Heartland Dental Care
Aspen Dental Management
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Senate Investigation R E P O R T E D & S T U D I E D
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
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Senate Investigation R E P O R T E D & S T U D I E D
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.”
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Intriguing Senate Panel Question… R E P O R T E D & S T U D I E D
If the fees are so low, why are there
millionaire dentists in Medicaid?
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Recent Updates
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23 Medicaid Expansion - 133% of Fed Poverty Level R E C E N T U P D A T E S
Table 1: Medicaid and CHIP: May and June 2014 Preliminary Monthly Enrollment
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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.
Era of Accountability:
RAC Audits
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How does it work? R A C A U D I T S
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).
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What do the facts
indicate? Aggregate per capita
cost by age
Extreme patient cases
“To those who should
be concerned…….”
Let’s Dig a Bit Further:
Proprietary Research
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Aggregate Market Data P R O P R I E T A R Y R E S E A R C H
All Regions
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Aggregate Market Data (continued)
P R O P R I E T A R Y R E S E A R C H
All Regions
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Eruption/Exfoliation P R O P R I E T A R Y R E S E A R C H
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Eruption/Exfoliation (continued)
P R O P R I E T A R Y R E S E A R C H
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Proprietary Research:
Extreme Patient Cases
Pulled from internal database
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Extreme Patient Cases P R O P R I E T A R Y R E S E A R C H
18 crowns before age 4 9 teeth crowned more than once
Patient A: 3 years old
$7,000 in restorative
services before age 4
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Extreme Patient Cases (continued)
P R O P R I E T A R Y R E S E A R C H
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
Patient B: 1 years old
$3,900 in one dental visit
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Extreme Patient Cases (continued)
P R O P R I E T A R Y R E S E A R C H
Patient C: 1 years old
$4,000 in one pediatric dental visit
26 procedures on same day, including: 10 Extractions 8 Crowns 1 Therapeutic Pulpotomy
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Extreme Patient Cases (continued)
P R O P R I E T A R Y R E S E A R C H
Patient D: 5 years old
$6,700 in dental services in one visit
All services received on same day 19 Crowns 10 Pulp caps 1 Pulpal therapy 3 Pulpotomies 1 Extraction
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Recent Extreme Patient Cases P R O P R I E T A R Y R E S E A R C H
Patient A: 2 years old
$7,700 in dental services
in one visit
All services received on same day 16 Root Canals 16 Crowns No anesthesia billed
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Recent Extreme Patient Cases (continued)
P R O P R I E T A R Y R E S E A R C H
Patient B: 2 years old
$3,600 in dental services in one visit
All services received on same day 16 Extractions Remaining 4 teeth received both a
Pulpotomy and SS Crown Remaining teeth: not upper/lower
corresponding
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Recent Extreme Patient Cases (continued)
P R O P R I E T A R Y R E S E A R C H
Patient C: 5 years old
$7,500 in dental services in one visit
All services received on same day All 20 teeth received a Pulpotomy and a Crown 4.5 hours of general anesthesia
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Recent Extreme Patient Cases (continued)
P R O P R I E T A R Y R E S E A R C H
All services received on same day 19 Crowns 10 Pulp caps 1 Pulpal therapy 3 Pulpotomies 1 Extraction
Patient D: 5 years old
$6,700 in dental services in one visit
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Recent Extreme Patient Cases (continued)
P R O P R I E T A R Y R E S E A R C H
All services received on same day 20 Surgical Extractions 4 Alveoloplasty 10 Other Surgical Procedures
Patient E: 3 years old
$10,600 in dental services
in one visit
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To those who should be
concerned…
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Fraud and/or abuse of young patients enrolled in
Medicaid is a continuing problem that needs to be
addressed.
Many dentists & clinics in
Medicaid do a great job
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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 © 2014 Scion Dental, Inc. CONFIDENTIAL & PROPRIETARY
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Age Banded Real Time Provider Profiling P R O V I D E R E D U C A T I O N
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Provider Education P R O V I D E R W E B P O R T A L
Custom reports allow provider to compare utilization vs. peers
Provider Web Portal
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Sanction
Program
P R O P R I E T A R Y Enterprise
System
Statistical Analysis/
Provider Profiling Hotline Tips
Client Notification
No Action Required
Provider Education Letter
Severe Allegation
Suspension or Termination**
Revised Behavior
Clinical Review (Chart Audit)
Able to Chart Audit
Alternative Reimbursement
Methods**
Additional Authorization or Documentation Requirements**
Aberrant Results in
Chart Audit
No
No
No
Yes
No
Yes
Yes
** Dependent on severity of aberrant behavior
Yes
Client Discretion
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Overutilization of CDT code D4341
Initial Intervention: Require
authorization
Behavior revised
Provider A – General Dentist
After sanction, CDT code D4355 is overutilized
Future intervention: Require authorization
on all periodontic codes
Sanction Program- In Effect P R O P R I E T A R Y
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Industry Collaboration
Institute for Research & Policy Formation
ADA
NADP
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Thank you for attending
We hope you find this information useful
We welcome your questions and comments
http://nadpconverge.org/evaluations