The TMHP document reported about in our last story that was recently appended to a court filing by Xerox shows that staff from the Health and Human Services Commission and its Office of Inspector General were well aware of the details of Xerox’s orthodontic prior authorization process. They knew because TMHP/Xerox did answer the five questions asked by Medicaid dentists about the process in 2007 although the dentists never got them.
State lawsuit holds prior authorization process misrepresented
The Office of Attorney General, on behalf of Texas, filed suit against Xerox in May of 2014 at the same time the company was terminated as its Medicaid claims administrator. The lawsuit alleges that the company’s prior authorization process for Medicaid orthodontic treatment was fraudulent because Xerox misrepresented its process to Health and Human Services Commission officials. Xerox was supposed to be obligated to have such requests reviewed by trained dental staff. Xerox has stated that HHSC knew and approved everything.
Document shows process represented accurately in 2009
While the qualifications, piece-work and working from home details were not included, TMHP/Xerox looks to have been pretty upfront about how the prior authorizations were approved. They told HHSC if the HLD score was 26 or more (the addition was checked) and x-rays submitted, a prior authorization request was automatically approved.
Here are those answers:
l. Who is involved in the review of orthodontic cases?
TMHP dental specialists review the information the provider submits. If the client has an HLD score of 26 or greater (measuring the dysfunctional malocclusion), and the provider submits the X-rays with the request, the request is authorized. If an HLD score of less than 26 is documented the request is denied. Except when the dental provider puts a note on the request about the medical need for orthodontia even though they do not have an HLD score of 26, then the request is referred to the TMHP Dental Director for review.
2. What are the criteria for the review of orthodontic cases?
If the client has a request submitted by a licensed general dentist, pediatric dentist or an orthodontist and the provider has submitted x-rays and the HLD scoring sheet with a result of 26 or greater, the specialists approve the request as per policy. If the x-rays are not submitted or the score is below 26, they deny the service. Except when there is narrative submitted along with the x-rays and the HLD score sheet with a result below Z6, the request is reviewed by the TMHP Dental Director. The guidelines in the medical policy must be met for the specialists to approve the orthodontia.
3. What is the process when a difficult orthodontic case is presented?
Any request that does not clearly meet guidelines but the provider submits information regarding why this should still be considered for approval (even though the guidelines are not met are reviewed by the TMHP Dental Director.
4. What is the level of understanding of orthodontics by the providers who present orthodontic cases?
According to the state law, any provider that is licensed by the State of Texas to practice dentistry can do orthodontics, This would include a general dentist, pediatric dentist, or an orthodontist.
5. What type of interceptive orthodontics is available for children in the age range of 6 to 7 years?
Currently, we authorize for treatment to correct an anterior or posterior crossbite.
So while HHSC was told, providers never were. They were told to expect that a board certified orthodontist reviewed each case!
The excerpted pages from the document shown below give the names of the staff from HHSC, TMHP, and OIG that were developing the new orthodontic policy along with the answers.
No issues of fraud, waste and abuse
Perhaps more importantly, the document indicates that fraud, waste and abuse by providers WERE NOT ISSUES considered in the policy revamp. This is despite the fact that in 2008, an OIG audit found that there was potential for fraud in the system. Certainly Xerox and its prior authorization process weren’t suspect!
Considering that HHSC staff had these details, the state’s allegations against Xerox appear weak.
Discussion about review by board-certified orthodontist
There was a discussion in the document about changing the review process so it was done by a board certified orthodontist but that is our next story.
The full document can be downloaded here.
If a store owner had been stricken with a sudden debilitating illness, the result being that he was take to a hospital and his business left unattended, would it be OK to go in and take his inventory, without paying for it, because it was apparent that the authorities knew the door was unlocked?
It seems apparent, despite Xerox’s failures, that much orthodontic treatment was performed, that a rational dentist could assume would not have been authorized by Medicaid. Is it really that hard to know what would or would not have passed muster?
While I applaud TDMR for pointing out the flaws in the system, it seems as if it is seeking to use those flaws to justify a rather significant amount of improper behavior. Is it unreasonable to expect health professionals to do the right thing, even if no one is looking?
Dr. Hindin
It is important to point out that the analogy you draw is not only inaccurate but severely flawed. It is the same one that has been thrown around in Texas for four years. The truth of the matter is that no one in Texas had an allegorical “illness” or “left their business unattended.” The state and its contractor knew full well, at all times, what was being done and how money was being spent. The document just released proves this point and there are a few more stories to come on this. Dealing with the culpability of dentists, from the administrative court decisions to date, all have found in favor of the dentist, finding no intention to defraud and finding they were following Medicaid guidelines as they were at the time. The fact that the Texas legislature in the last two legislative sessions revamped due process rights for Medicaid providers and reformed the office of Inspector General adds further proof. This should answer your question.
A more accurate analogy is that a sub-contractor is working hard every day, working on a project, doing what was called for and billing the same per his contract. So it goes on for years. Then the client (Texas) finds suddenly that his friends (other states) are spending less money on a similar project and is embarrassed because they are supposed to be the smartest and most penny-pinching. Because the client is good friends with his general contractor (Xerox), he accuses the sub-contractors of defrauding him so he doesn’t lose face with his friends and the public. Because the sub-contractors aren’t deep pockets, the client gets a perverse satisfaction out of bankrupting them or harassing them for settlements they can ill afford to pay so he doesn’t have to prove they did anything wrong. The client (Texas) is well-known for hating the project (Medicaid) anyway so it doesn’t matter what happens to the sub-contractors or the project. Because the client is yelling so loud about fraud, his bank (the federal government) investigates and finds that the client himself, not the sub-contractors, set the criteria for the project too low and in violation of their funding agreement and demands repayment.
Is this a way of arguing that all of the approx. $174 million spent by TX was for appropriate othodontic treatment?
Are you giving all dentists a pass and laying the blame for it all on Texas and Xerox?
Dr. Hindin
You seem to have a low opinion of your colleagues. You’ve never worked in the Medicaid system, have you?
I have treated Medicaid patients, in community and private settings, since 1975 and still do.
It has never been really difficult to know what was and was not a covered service. Orthodontics is not my area of expertise, but a close friend, a Board Certified Orthodontist, who also treats Medicaid has often discussed “the system.” Of course there are grey areas, but in ortho as well, it is not, for the most part difficult to know what would or would not be covered. Granted that some errors can be expected.
I give TDMR a lot of credit for exposing the failures in the system and raising the big questions regarding how they got there. It is an apparent willingness to turn a blind eye to what almost certainly had to be abuses, on the part of dentists, that diminishes the organization’s stature. The vast majority of dentists are completely ethical, hard working and very caring professionals. I am privileged to know many. There will always be some who are not.
It diminishes us all when they are protected by even well meaning colleagues.
$174 million in ortho billing is a lot of money, certainly enough to make one wonder whether a good part of it really went towards helping children who really needed it.
Allen Hindin
Dr. Hinden
Your surmise is a rational one but no matter how attractive and rationale it seems, it does need evidence to back it up. So far, after four years, there is no evidence supporting a rampant ripoff of the Medicaid orthodontic program by Texas dentists. I suggest you read the ruling in the Harlingen Family Dentistry case to gain an understanding of why this is the case.
Dr. Hinden, your comments reflect exactly what happened here. TDMR can’t see past their noses and they defends every dentist who made millions from Medicaid for claiming children with straight teeth were handicapped. TDMR and the dentists who took advantage of the flaw in they system (aka unattend store), merely lucked out because judges hearing those cases sided with a flawed explanation of ectopic eruption. Lawyers used smoke and mirrors to twist a common and well know medical/dental term (ectopic eruption) into something that would justify their false claims. Kind of how the lawyers fooled the jury in the O.J. Simpson trial. Simply fancy lawyering that’s all.
For a laugh, why don’t you tell us how you “know” these things?