Why Do Almost All DentaQuest Audits End with $20,000 Recoupments?

The list of complaints about DentaQuest from Medicaid providers keeps growing. It seems that new Canadian ownership hasn't changed any business practices so far, but we hear they like their money too.

While some problems have been reported about MCNA and UnitedHealthcare Dental, they haven't been a real concern to the Medicaid dentists to which we have spoken. The most fervent provider upset and frustration now comes only from DentaQuest. Just look at the number of comments and complaints in our articles about the three-year rule which was started by DentaQuest.

Here are a few other major concerns that have recently popped up.

Culling the provider herd

DentaQuest has apparently started a culling of its network, ridding it of the highest utilization providers. This is according to Jason Ray, the Austin administrative attorney who represents many Medicaid dentists.

He told us that it was not even a secret that DentaQuest would do this. Company reps told him as far back as 2012, when they first entered the Texas market, that they planned to build up their network and then, once the network was more than sufficient, pare it down by terminating those that did not consistently meet the standard of care. Their DMO contract with the state only requires that the company maintain an adequate network to serve Medicaid clients, not a large one, they said. Ray had expected this culling for years and felt it had been delayed by the pandemic. But he said it is happening now as dentists that have been terminated by this culling are seeking legal counsel.

Ouch.

Appears to only audit high volume practices

A second concern we came across about DentaQuest this past month came from a practice with a large number of offices across the state, both in rural and urban settings.

First of all, their experience is that DentaQuest only ever audits high-volume urban practices and never has audited smaller rural offices even though they are productive.

The second and most interesting concern is that every high-volume office audit ends in a recoupment demand of around $20,000. Usually, there have been some clinical reasons for the recoupment. They find some procedure or procedures that haven't been done properly according to them. For instance, they regularly go after fillings. Sometimes the x-rays don't show that the fillings reached the dentin so they want to recoup that work.

Doesn't provide specifics for correction

A lot of times however the company doesn't provide specifics of the problem. Instead, it provides a general cookie cutter type allegation and when even pressed for details doesn't supply them.

For instance, an audit would allege that a dentist didn't meet the standard of care. The practice would ask for details and even ask for training so they could correct whatever the problem might be. But the company would provide no further explanation even upon appeal.

One ridiculous example happened with sedation documentation. The audit indicated that "sedation documentation inadequate." But when pressed for which of 50 documentation requirements weren't met in a peer-to-peer, the DentaQuest auditor refused to say until the company's clinical doctor on the call got angry. The inadequacy turned out to be that vitals weren't recorded at 10-minute intervals per the auditor. But the practice documentation showed that vitals were recorded at 10-minute intervals and those documents were presented to the company on appeal. The company still denied the appeal.

Had to hit $20,000 recoupment target

But the most egregious example was the audit of a relatively new practice. Hardly anything clinical was found. However, the audit alleged that because the doctor's notes weren't signed that a $25,000 recoupment was owed.

Apparently this appears to be a requirement in the Medicaid Manual, but not a requirement per the Texas Dental Practice Act. All providers were clearly identified in the clinical notes, as required by the Dental Practice Act. This has never come up in any previous audit for the practice with any DMO although all doctor's notes are done in the same manner -- the doctor's name is typed.

Money grab for harmless paperwork errors

It's just a plain money grab. But that's what these audits seem to be all about.

For those familiar with the OIG audits from a few years ago, these tactics might sound familiar. Seek out small paperwork errors, ignore the fact that quality care was provided to needy children; and then demand massive payouts for harmless paperwork mistakes.

This is the worst type of oversight as it is designed solely for the benefit of the insurance company and does nothing to improve care for kids