Some of the evidence that the state is using to pursue Medicaid fraud allegations against its former Medicaid claims administrator on its orthodontic prior authorization program from 2004 to 2012 comes directly from depositions of the Xerox/Conduent dental director, Dr. Jerry Felkner.
Xerox/Conduent kept telling the state in their policy manuals that he was reviewing cases when, in fact, he wasn’t.
Xerox PA manuals included dental director review
The company’s 2004 Dental Authorization Department Policy and Procedures Manual given to HHSC states for the ortho PA [excerpted]:
- After the request is checked for eligibility and duplications, the Dental staff will unwrap the corresponding dental molds and prepare them for display.
- The Dental Director will review the request online, and review the necessary molds, x-rays and images pictures.
- The Dental Director will place the decision in the comment screen of the client’s Phoenix authorization screen.
- When the authorization process is complete, the Dental staff will re-box the molds and secure for mailing.
In March 2009, Xerox had revised its P&P to state [excerpted]:
- All PA requests, including documentation or information received on the phone, must be reviewed for completeness and medical necessity. The TMHP nurse or specialist will determine if the request is a complete request, a duplicate or incomplete”.
- Requests are processed to ensure that all eligibility, medical policy criteria, and benefit limitations are reviewed and enforced.
- A ‘complete’ request has all the necessary information included to make a proper determination on the request at that time. After reviewing all of the documentation and information, the services are approved, modified, or denied using appropriate reference materials…and approved medical policy.
- Once the Prior authorization determination is made, the provider is informed of TMHP’s determination by letter…
Forced inclusion in 2009
But then-Texas Medicaid Director Billy Millwee apparently questioned the lack of dental director review in an email to the company representative Eric Holt.
So in April, Xerox/Conduent responded to include:
“The Medical Director reviews the request and determines the appropriate processing of that request…”
But he never did.
Less than 10% went to dental director
Per the court document TDMR has, the state says “Xerox has admitted that instead, 10% or fewer of PA requests went to the Dental Director; the remaining 90% or greater of PA requests went to the Dental Clerks for review. Xerox has admitted there is no language in the P&P statements above that notified HHSC that for the overwhelming majority of dental prior authorization requests the Dental Clerks, not the Dental Director, were reviewing the requests.”
Approved them all
Further, “Xerox’s Dental Director from 2004 to August 2011, Dr. Jerry Felkner, has admitted that both he and the Dental Clerks did not actually perform a prior authorization of the ortho PA requests but rather, simply approved nearly all the requests regardless of whether the requests met the Medicaid policy criteria or not.”
Felkner, in depositions, said
Q. Is it a true statement to say that you approved nearly everything that you reviewed regardless of whether it met Medicaid guidelines for medical necessity?
A. Yes.
Q. Is it a true statement to say that if the HLD score sheet was. filled out and the supporting materials were there and the eligibility of the recipient was confirmed the application would be approved regardless of medical necessity?
. For me or for the clerks?
Q. For you.
A. Yes.
Q. And can you comment also about the clerks based on what you know?
A. Well, the clerks, again, were looking at the arithmetic. If the arithmetic added up they approved it.
Q. So there really wasn’t any determination of medical necessity going on in terms of evaluating the underlying data, correct?
A. No.
Q. Is that correct?
A. That’s correct.
Further Felkner said of those applications he looked at personally that he just approved all of them regardless of HLD scoring or age of the patient.
Q. Did you ever come to have an understanding that applications with HLD scores of less than 26 might still
meet medical necessity criteria under Medicaid?
A. Well, technically they could have a malocclusion; however, I approved all of them regardless.
Q. And when you say you approved all of them, tell us what you mean.
A. The applications that came in, even if they were under 26 I approved them; even if they were under age 12 I approved them.
Q. All right. And did you do that from the beginning of your tenure throughout the time that you left in 2011?
A. Yes.
Q. Did that process that you just described of approving all applications regardless of the score and regardless of the age, did that ever change?
A. No, sir.
Q. You understood it was the responsibility of ACS to review the underlying data included with the orthodontic prior authorization applications to confirm medical necessity, correct?
A. Yes.
No criminal investigation of company or staff?
Considering that the state knew about the flawed process in 2008, one has to wonder why Texas dental providers were ever targeted at all by the state and why there was no criminal investigation into the conduct of Xerox/Conduent executives and staff that apparently manipulated Texas Medicaid.
The excerpts of Felkner’s testimony are below:
OMG TDMR….everyone knows TMHP was clearly not reviewing anything and is the primary reason this problem ever happened in the first place. Is this really news? What is still a complete enigma is how your website continues to defend all the providers who reaped the benefits of this non-existent process. Trained and highly educated dentists who clearly knew what a severe (key word!) handicapping (another key word!) malocclusion was, yet submitted prior auth documents when this condition never existed. Do you actually believe this NEVER happened?! I bet they miss all of that extra cash now that the State pretty much shut the vault. Everyone eventually gets their comeuppance; if not in this lifetime, perhaps the next. The “guilty” providers know who they are.
If everybody knew, why didn’t you do something about it?
It only came to light due to the diligence and persistence or Byron Harris of Channel 8 News investigations. No one would have ever known.
Joe Knows is only partially correct. Everyone did not know that they could blatantly lie on a state document and get away with it. There are many providers who played by the rules. Probably most. There were also a number who saw an opportunity to get very very rich by adding up to 26 as many preauths as they could get in the door. Because tmdr fails to acknowledge the deception of the abusive providers, the truly innocent get painter with their guilt. That is why tmdr ultimately lacks credibility, which is unfortunate.
Any dentist the state took to SOAH on such allegations was vindicated. State dental expert witnesses were found not credible using such arguments as you espouse. Those are the facts.
Many of you obviously don’t accept Medicaid. If a patient comes in and the parents ask if a crown is covered or ortho or whatever, the provider must send a preauth for determination of benefits. As a provider you can’t just tell the patient, in my opinion, this will not be covered. The patient and parent will insist you send a preauth. If the preauth is approved you must have a rationale for not providing the care.
I’m not saying there weren’t abuses, but the rules of the game put the provider in a poor position between a rock and a hard place.
Thanks for your input.
That is baloney, TEX. There was no penalty to a dentist for determining that a kid did not meet the ortho pre-auth requirement and deny services that were not covered under Medicaid. Zero. If the parent took the kid to another provider who knew how to add up to 26 and obtain coverage, that was their right.
Actually, the State website says that if a dental service is prior authorized, the dentist must provide the service.
“The provider requesting and receiving authorization for the service also must perform the service and submit the claim.” and “Providers must not bill a client unless a formal denial for the requested item/service has been issued by TMHP stating the service is not a benefit of Texas Medicaid and the client has signed the Client Acknowledgment Statement in advance of the service being provided for that specific item or service. A provider must not bill Medicaid clients if the provided service is a benefit of Texas Medicaid.”
http://www.tmhp.com/Manuals_HTML1/TMPPM/Archive/2012/Vol2_Children's_Services_Handbook.17.271.html
The real sham here is how those Medicaid “proceeds” bought the dentists a fancy lawyering trick where they convinced judges (with zero knowledge of dentistry) that an ectopic eruption is something other than what it really is. Fancy lawyering got them all off the hook and the dentists who were accused, unethically got behind that argument when they knew what dental schools and textbooks teach about ectopic eruptions. If you believe these lawyers and dentists, this world has a pandemic of ectopic eruptions, which should bring about the end of mankind. The malocclusions are so wrought with ectopic eruptions, the large majority of the world is handicapped to the point they can’t chew food and can’t annunciate correctly. How can it continue to function amidst all of this severe handicapping?! Medicare for all….no…we need braces for all!
[…] the doctor in charge of reviewing hundreds of cases a day, Dr. Jerry Felkner, said in court depositions that he had approved cases without ever even evaluating them. Even for the ones he did […]