Credentialing Slowdowns Crippling Access to Care for Dental Medicaid

Texas is grappling with a critical shortage of healthcare workers, including dental professionals, exacerbating dental access and provider issues across the state. A recent Newsweek article, “How Texas Could Solve Its Health Care Worker Crisis,” highlighted these problems, mentioning a Becker’s Dental Review article cited by TDMR that Texas has the lowest number of dental hygienists in the nation.

Proposed legislation filed

Texas House Bill 1803(see below), recently filed by House Rep Sam Harless, who represents District 126 northeast of Houston, attempts to address these shortages by introducing the Dentist and Dental Hygienist Compact. This compact facilitates the interstate practice of dentistry, aiming to attract more providers to Texas and alleviate the strain on the healthcare system.

While promising in theory, the compact fails to address a significant roadblock for Medicaid practices: the inability to credential dentists promptly with TMHP and DMOs. This has been a bane for many years, which TDMR has reported on a number of times which just doesn’t get fixed. We even sent a complaint to OIG about it in 2023.

Complaints have again cropped up. It is unbelievable that even in the easiest conceivable circumstance, a dentist already approved for one location needing to be credentialed in another by a DMO can face months of delay. This does not serve those Medicaid patients who need care immediately.

DMOs have a contractual obligation to credential promptly

Under the DMO contract (see below) governing Medicaid dental services, there are explicit timelines in Section 2.3.12 that DMOs must follow for credentialing. The contract states:

“The Dental Contractor must complete the credentialing process for a new provider, and its claims system must be able to recognize the provider as a Provider no later than 90 calendar days after receipt of a complete application.”

 If there is missing information:

“If an application does not include required information, the Dental Contractor must notify the Provider in writing of all missing information no later than 5 Business Days after receipt. If the provider responds with the missing information within 10 calendar days of receipt of the written notice, the Dental Contractor must complete the process within 90 calendar days from receipt of the original application. If the provider responds with the missing information after more than 10 calendar days of receipt of the written notice, the Dental Contractor has 90 calendar days to complete the credentialing process from the date of receipt of the completed application.”

Under Section 2.3.12.3 Expedited Credentialing Process states:

“The Dental Contractor must establish and implement an expedited credentialing process, as required by Tex. Gov’t Code § 533.0064, that allows applicant providers to provide services to Members on a provisional basis for the following provider types:

1. 1. Dentists; and
   2. Dental specialists, including dentists and physicians providing dental specialty care.

The Dental Contractor must allow providers to qualify for expedited credentialing if the provider:

1. 1. Is a member of an established dental care provider group that has a current contract in place with a Dental Contractor;
   2. Is a Medicaid enrolled provider;
   3. Agrees to comply with the terms of the contract between the Dental Contractor and the dental care provider group, and
   4. Timely submits all documentation and information required by the Dental Contractor, as necessary, for the Dental Contractor to begin the credentialing process.

Additionally, if a provider qualifies for expedited credentialing, the Dental Contractor’s claims system must be able to process claims from the provider as if the provider was a Network Provider no later than 30 calendar days after receipt of a complete application, even if the Dental Contractor has not yet completed the credentialing process.”

For those providers that apply and are denied, the contract says:

“The Dental Contractor must not discriminate for the participation, reimbursement, or indemnification of any provider who is acting within the scope of his or her license or certification under applicable state law, solely on the basis of that license or certification. If the Dental Contractor declines to include individual or groups of providers in its Network, it must give the affected providers written notice of the reasons for its decision.”

So why don’t they do it?

One reason is that DMOs “… must utilize the Texas Association of Health Plans’ (TAHP) contracted Credentialing Verification Organization (CVO) as part of its credentialing and recredentialing process regardless of membership in the TAHP. The CVO is responsible for receiving completed applications, attestations, and primary source verification documents. The Dental Contractor retains the sole responsibility for credentialing the Provider.”

The communication between the DMO and CVO can be slow, slow, slow. If the DMO doesn’t send all the information for verification, the CVO has to request it. Takes time, blah, blah, blah. We’ve written about this.

More cynically, it is possibly a way for a DMO to limit its network just as DentaQuest recently tried to do.

What can a provider do? There is a process

One might think HHSC dental Medicaid personnel have some purview over this. This is not the case that we have found.

It is a contractual issue to be dealt with by HHSC Provider Contracting.

There is a process, as shown in the PDF below.

Step 1 – write or call TMHP.

Step 2 – complain to HHSC via online form or email.

Lots of complaints might help move things

This might seem lame, but something might happen if several hundred complaints appear in that inbox.

For good measure, find the contact information for your House Representative and State Senator and send them a copy of any correspondence you send or receive by both email and mail.

That wheel has to be made very squeaky indeed.