For those following the $2 billion Medicaid fraud case against Xerox/Conduent here in Texas, another plank in the state’s case against the company is that it alleges that no meaningful Quality Assurance check was ever done to ensure medical necessity on some 500,000 orthodontic prior authorizations the company approved from 2004 to 2012.
“Can’t recall”
Under deposition, Xerox/Conduent’s dental director, Dr. Jerry Felkner, said there was none he could recall.
Q. My next question was, was there any routine quality assurance performed to ensure the accuracy of the orthodontic prior approval process?A. Not that I can recall.
Xerox representatives who were deposed didn’t seem to grasp the concept of such a review in the excerpts of their testimony provided in a state court filing. They had no idea that x-rays and other supporting physical evidence provided by dentists requesting prior authorization should be examined in a review to ensure medical necessity.
Didn’t look at x-rays, models in review
It appears from the testimony the primary Quality Assurance review point was to ensure the Xerox dental “specialists” addition of the HLD score sheets was correct.
Q. Well, that’s an interesting answer to me because it indicates to me that your quality assurance process did not include checking — in the instance of orthodontia prior authorizations it did not involve looking at the actual medical documentation and comparing it to the submitted application to see if in fact medical necessity existed in accordance with what’s represented on the score sheet. Would that be correct?A. You mean like the — the x-rays again?
Q. Yes.
A. I don’t think that — I do not think that’s part of the process.
Q. And that wouldn’t have been the process in reviewing Dr. Felkner’s work either?
A. No.
Exh. 33 – Xerox Organizational Representative Ty Clift March 8, 2013 Q. As far as that quality assessment, would you agree with me that it did not include a check as to whether or not the client’s medical records supported the score on the HLD sheet? In other words, they weren’t looking at — they were not graded on whether or not that client did in fact exhibit the condition that would warrant Medicaid treatment, right?
A. That the quality review — I mean, if — if they approve something that wasn’t a 26, that would be a spot on the quality review.
Q. Okay. So the review did include looking at the score sheet to see if there was a 26 or above on it?
A. Yes.
Q. But the quality review never included looking to see if the x-rays that were submitted or the photographs that were submitted or the model that was submitted, if such were submitted, supported the score
of 26 or above?
A. No. Correct.
Exh. 34 – Suzanne Price February 22, 2013