In July, the Louisiana Legislative Auditor’s office published a scathing audit review of DentaQuest’s performance as one of the two dental maintenance organizations with Louisiana Medicaid. It fined the company for its poor performance. FYI, Louisiana calls them dental benefit program managers (DBPMs) rather than DMOs.
The Louisiana Department of Health back in January 2021 contracted with DentaQuest and MCNA to provide dental benefits for the state’s Medicaid-eligible population. The contracts were for two years. Last year, as the contracts ran out, MCNA was granted a two-year extension to 2025, but DentaQuest’s performance was so underwhelming that the Louisiana legislature only granted DentaQuest a one-year extension, pending the audit just completed.
Didn’t meet 85% Medical Loss Ratio
The first troubling issue found by the audit was that DentaQuest did not meet its medical loss ratio target, requiring it to refund over $9 million to the state.
The report states: “Because DentaQuest did not meet the contract requirement to spend at least 85.0% of its PMPMs on dental benefits and services, it had to refund LDH approximately $9.1 million for calendar years 2021 and 2022. However, DentaQuest’s Medical Loss Ratio (MLR) improved from calendar year 2021 to 2022.”
Lack of network
The audit found that DentaQuest’s provider network was inadequate. It states: ” DentaQuest did not meet all requirements for network adequacy as of June 2023 or June 2024. However, according to an LDH report, Louisiana has a shortage of dental providers across the state.”
Penalized for contract violations
Most alarming is that DentaQuest was fined a further $2 million for contract violations.
According to the report: “Between January 2021 and August 2023, LDH issued $1.1 million in penalties to DentaQuest for 19 instances of noncompliance with the DBPM contract. It issued $935,000 in penalties to DentaQuest for ten instances of noncompliance between September 2023 and June 2024.”
These include:
- Failure to meet performance standards
- Failure to maintain required business hours
- Failure to meet compliance in availability of services, assurances of adequate capacity and services, coverages and authorizations of services, provider selection, enrollee rights and protection, grievance and appeal systems, practice guidelines, health information systems, quality assurance and performance improvement, and fraud waste and abuse
- Failure to meet Healthcare Effectiveness Data and Information Set (HEDIS) performance measure target rate for sealants by 15.28%
- Failure to meet performance standards in encounter reconciliation reports
- Continued complaints that DentaQuest is inappropriately denying requests for prior authorization due to lack of medical necessity and engaging clinicians who lack the appropriate experience to make those decisions and participate in peer-to-peer meetings with providers.
Regarding providers, the report notes that: “The most common DentaQuest grievance was related to quality of care issues, while most appeals were related to denials or limited authorizations of services that had been previously authorized.”
Several provider complaints were discussed:
Providers noted continued issues with denials of claims. Some providers reported that the denials are inconsistent with current clinical best practices and guidelines and are the opposite of what is being taught in dental school residency programs. One provider stated, “Perception is that they are looking for ways to save money so they can show the state that they are saving, but they are denying medically necessary and needed care. Providers are going to stop accepting them if this continues.
One concern noted by several dentists was the peer-to-peer review, a tool available to providers to resolve disputes that may arise between a provider and DentaQuest. These reviews provide a means for resolving differences of opinion and focus on appropriateness of care, quality of care, and fees. Several dentists stated that the peer-to-peer reviewers are not truly peers, citing the example that a general dentist is conducting the review instead of a dentist of their specialty (i.e., pediatric dentistry, oral surgery, etc.) who would have the training and expertise to address concerns.
Providers noted that there are issues with the timeliness of DentaQuest’s credentialing process. Often times, these are dentists who recently graduated dental school. While providers feel it is reasonable that it could take up to six weeks for a provider to be credentialed, they stated that it takes six to 12 months in some cases. One provider reported that their application was lost on three occasions, despite being sent electronically, by mail, and by fax. Providers stated that MCNA will provisionally credential a provider with the understanding that the dentist would have to repay any amounts paid if their application is denied; however, DentaQuest does not do this.
The report has gone to the Lousiana legislature for its consideration.