A few weeks ago, we published our analysis of the latest Texas Health and Human Services Office of Inspector General quarterly report and were struck by the fact that despite the large number of Medicaid health professions represented, dentists received a lion’s share of attention.
Do dentists get more attention? Yes
So we sent off a question about this to the OIG. We want to thank OIG communications director, Dr. Andrés Araiza, for answering us. His answer was very enlightening and led to an interesting discovery.
Our question: As pointed out in the article on the OIG Quarterly Report, Medicaid dentists are investigated at a much higher rate than the complaints received. Also, the report mentions Medicaid dentistry and dentists more than the medical profession. Is there some sort of focus by OIG on Medicaid dentistry as being more likely to commit waste, fraud and abuse than other healthcare professions?
His response: The Office of Inspector General (OIG) receives referrals from many sources, including the public, MCOs/DMOs, and its own data analytics. As directed by statute, the OIG allocates its resources to cases that have the strongest supportive evidence and greatest potential for recovery(1).
The OIG is also directed by a rider in the appropriations bill to strengthen the capacity of Texas Health and Human Services to detect, investigate and prosecute abuse by dentists and orthodontists who participate in Texas Medicaid(2). The OIG does not prioritize a particular provider group over another but focuses on the facts and evidence of each case.
1 Government Code 531.102 (b)
2 General Appropriations Act, HB 1, 86th Legislature, Article II, Rider 115
Legislative mandate to investigate!
We did not know about Rider 115 in the state budget legislation HB 1 so we checked.
This is what it says:
115. Dental and Orthodontia Providers in the Texas Medicaid Program. It is the intent of the Legislature that the Health and Human Services Commission (HHSC) use funds appropriated above in Strategy K.1.1, Office of the Inspector General, to strengthen the capacity of the HHSC Office of Inspector General to detect, investigate, and prosecute abuse by dentists and orthodontists who participate in the Texas Medicaid program. Further, it is the intent of the Legislature that HHSC conduct more extensive reviews of medical necessity for orthodontia services in the Medicaid program.
[Strategy K.1.1. is the OIG budget allocation]Every budget since early 2011
Further research showed that this rider goes back to HB 1 of the 82nd Legislature, signed into law June 17, 2011 by then-Governor Rick Perry. Then it was Rider 82.
It essentially uses the same words.
Monies for evaluation of dental managed care in same budget
This 2011 budget for 2012-2013 spending also includes Rider 54, a directive to evaluate a capitated managed care model to deliver dental services. The deadline to submit the report to the Governor was March 1, 2013.
Capitated Managed Care Model of Dental Services Reporting. Out of funds appropriated above to the Health and Human Services Commission in strategy B.3.2, Health Steps (EPSDT) Dental, contingent on the Health and Human Service Commission changing the service delivery model for dental services from a fee-for-service model to a capitated managed care model, the Health and Human Services Commission shall evaluate the impact of providing dental services through a capitated managed care model on access, quality and cost outcomes. The evaluation shall address issues including but not limited to utilization trends, penetration rates, provider to client ratios, retention of dental providers, services provided, premium insurance revenue and managed care premium cost growth. The Health and Human Services Commission shall submit findings to the Governor and the Legislative Budget Board by March 1, 2013.
OIG mandate to investigate added by joint House and Senate Committee
The genesis of Rider 83 is that it was put into the bill on May 24, 2011, by the House and Senate Conference Committee, which finalized the budget before being sent to the Governor. From one of the budget documents, it appears it was the House members of the Committee that included it in the proposal.
The impetus apparently was the airing of the first investigative report by WFAA on the amount of orthodontia spending in Texas – “Texas Citizens Picking Up The Tab for Unnecessary Orthodontics” on May 13 (the above link gives the story a date in August but it aired in May 2011).
Byron Harris reported scathing facts about ACS/Xerox/Conduent admitted by HHSC
It is surprising to re-read this piece and realize how much of the complete story Byron Harris had at that time, not just the lurid claims of dental Medicaid fraud he reported from others that we and other media have debunked many times over the years.
“Medicaid claims are processed by an outside contractor in Texas. According to the Department of Health and Human Services, claims are rejected only if paperwork is incomplete, not on a standard of medical evaluation.”
Quite an admission by HHSC! It wasn’t until three years later that the state fired and then sued ACS/Xerox/Conduent.
“A dentist, the state says, oversees a team of four people that do not have dental backgrounds. The dentist consults on close calls.”
Another major admission to Harris. HHSC knew former janitors were approving HLD scoring sheets and prior authorization requests. HHSC let this go on.
“The Department of Health and Human Services is aware of a potential problem.”
HHSC admitted it all to Harris but it was denied and submerged for years.
Legislature moved quickly unlike HHSC
It is gratifying to know that the Legislature moved quickly on what they were told the problem was. It took them only in 11 days. They didn’t wait around.
HHSC and OIG itself knew about the broken ACS/Xerox/Conduent prior authorization process in 2008 and did nothing until Byron Harris came along.
Paved way for fast tracking of DMOs
The end result of the WFAA expose was the State of Texas bringing in dental managed care without an open bidding process in early 2012, not HHSC just putting a viability report on the Governor’s desk by March 2013.
It would be interesting to know how much money is actually collected (not identified for collection) each FY from dental investigations vs. what is allocated in the budget each biennium to conduct these investigations.