Credentialing Still a Disaster for Texas Medicaid Dentists

Over the last several months TDMR has been receiving an increasing number of complaints regarding credentialing for Texas Medicaid dental providers.

There have been numerous fixes over the years such as PEMS, the Provider Enrollment & Management System, which is supposed to speed up credentialing with TMHP via its online portal. Then for DMOs and MCOs, there is the Texas Credentialing Alliance which uses Aperture Credentialing, LLC, to streamline the DMO process supposedly.

One provider just told us it took six months to get a dentist credentialed with DentaQuest.

Emergency credentialing needed

A major complaint is the extreme length of time it takes to credential dentists who are needed for emergency or substitute situations for a new location even though they are already credentialed for others in the same practice. The need is immediate and unpredictable, yet the powers that be have no sense of urgency or care.

The situation is best explained in a letter to Texas HHS from administrative law attorney Jason Ray who forwarded TDMR a copy.  Ray, based in Austin, is well-known for representing Medicaid providers including the late Dr. Juan Villarreal who founded TDMR.

Here are salient portions (the full letter is below):

"Although I notified HHSC of the problem in 2018-2019, there continues to be an unreasonable inability to get new dentists timely credentialed to provide services for Medicaid patients through TMHP and the DMOs. The expedited credentialing initiative that used to be available for dentists appears to have deteriorated into a mess of finger-pointing and bureaucratic excuse-making that has resulted in a systemic regression to near gridlock. Certainly HHSC is aware of TMHP’s current backlog of dental provider TPI applications. I am being told that TPIs are now taking 30-60 days to be issued, and often much longer—and this includes issuing new location TPIs for dentists that are already Medicaid credentialed at group practices that enjoy expedited credentialing for their new providers. All of the DMOs report that they will not begin DMO credentialing a dentist for a new location until a new TPI has been issued by TMHP, even if the dentist is already Medicaid credentialed at another location for the group practice. That creates an exception to expedited credentialing that seems to swallow the purpose of expedited credentialing.

"Here is an example. Suppose a group dental practice in North Houston needs a dentist to cover patients at their South Houston location for a month while the regularly scheduled dentist for the South Houston location recovers from a sudden illness. Stated directly, the North Houston dentist is simply moving across town to treat South Houston patients with the same employer. Although the North Houston dentist is credentialed for the North Houston location, the North Houston dentist must apply for a new location-specific TPI, which usually requires at least 30 days to be issued. Only then will each DMO permit the dentist to begin the credentialing process for the DMO. None of the DMOs issue credentialing approvals that are retroactive to the TPI issuance date, which means that there is an additional 30 to 60 days after the TPI has been issued before the dentist is able to see patients at the South Houston clinic. Thus, it is effectively impossible for a group practice to simply have another dentist cover for the South Houston location for at least 60-90 days. That leaves the scheduled (and emergency, non-scheduled) South Houston patients without a dentist for a long time. When a dentist with full (both TMHP and DMO) credentialing at a group practice location needs to help cover for a sick dentist at another group practice location, it seems unreasonable and unnecessary for the group practice to have to wait 60-90 days before it can provide Medicaid services to its patients.

"My clients and I have been consistently told that TPIs are issued by TMHP to assure that Medicaid dentists meet a higher qualification standard than simply being licensed by the Texas State Board of Dental Examiners. We also understand that issuing a TPI for every location that a provider serves is a utilization and audit tool. However, once a dentist has been TPI’d at one location, every additional TPI issued to the dentist (presumably for a new or additional location) has very little to do with the dentist’s qualifications or fitness to serve Medicaid patients. After all, if TMHP believes that the dentist is currently qualified to serve patients in a North Houston practice, why is there a two month lag in making a decision that the dentist can be TPI’d for a dental practice in South Houston? Likewise, although my clients understand that the DMOs have their own processes and standards for credentialing their providers, it seems burdensome and harassing for DMOs to be allowed/required to demand completely new applications (along with copies of diplomas, dental licenses, etc.), then vet that application for months, for a dentist that is already credentialed in their system and simply is moving to a new or additional location.

"Dental clinics need your guidance regarding how to correctly use substitute dentists. In 2016-2017, Texas Medicaid took the position locum tenens was no longer acceptable in dental offices. Instead, practices are to employ substitute dentists pursuant to Rule § 354.1221. The DMOs seem to all have differing positions as it relates to substitute dentists. One DMO does not allow substitute dentists at all. Those that do allow substitute dentists only allow them if the substitute dentist (the treating provider) is fully credentialed by TMHP and the DMO at the specific location prior to rendering any treatment to patients. But requiring full DMO credentialing for the location in advance of having a substitute dentist see and treat patients at the location is absurd, because it requires the practice to predict every emergency, find a substitute, and begin attempting to credential the substitute six months in advance of the emergency. Moreover, once a new dentist is fully TMHP and DMO credentialed at the new location, they are no longer a “temporary substitute” for the original dentist at that clinic—they are a fully credentialed dentist that can see all the patients. Thus, the substitute dentist Rule has being effectively invalidated, because the temporary relief the Rule is supposed to provide to clinics has been nullified by the DMOs' requirement to be fully DMO credentialed before treatment can occur."

This letter was sent in late October. There has not been a response to these issues.

Providers are supposed to be important

TMHP says, "Providers are the crucial players in any quality health-care program. Providers enrolled with Texas Medicaid and other health-care programs render essential medical and preventive health-care services to clients while focusing on providing the best medical care possible. Texas Medicaid providers help ensure that each patient can receive high quality, comprehensive health-care services within their community."

DentaQuest tells providers, "Not part of our dental provider network? Join now and make an impact! You can make a positive impact on the oral health of your community while making a positive effect on your practice. We go beyond the chair, connecting oral health leaders and the broader health community to improve access and outcomes for everyone. And we want you to join us."

So, if providers are so important, why this delay in credentialing? If patient care is so important, why harm their care in this fashion?