Apparently TMHP/Xerox “dental specialists” were only trained to add up HLD scores on Medicaid orthodontic pre-approval requests and determine whether the total was 26 points or more, per allegations contained in the lawsuit filed against Xerox by the Attorney General of Texas.
Approved $700 Million in Orthodontic Pre-approvals
These Xerox staff approved some $700 million in Medicaid orthodontic pre-approvals between 2008 and 2011. They had no other specialist training, apparently.
Only added up the scores
The state’s pleadings state:
Xerox represented to HHSC that the “medically knowledgeable” analysts only approved those applications with a “verified” score of 26 or above. ln fact, Xerox personnel were not trained to check the validity of a score of 26 or above. On or about July 19, 2011, in response to continuing requests for clarification by HHSC, Xerox finally admitted: “[Xerox] ‘validates’ the score by mathematically calculating the providers recorded numbers to ensure the score totals 26 or higher.”
So, since at least 2008, HHSC-OIG and the state knew that TMHP/Xerox “dental specialists” were working from home, did not have access to the medical information submitted by dentists and orthodontists and took three years to get confirmation that these Xerox employees had no other dental training. And the State renewed Xerox’s contract as the state’s lead Medicaid contractor during that time.
Misrepresentation
In fact, in 2009, Xerox submitted documentation and representations relating to a continuation of their Medicaid contract with Texas relating to their orthodontic pre-approval procedure:
“PA staff review and consider all medical facts submitted by a provider . . . when determining medical necessity for requested services. Before making a PA determination we research. analyze. evaluate, and ensure we consider all documented medical facts, in accordance with State approved criteria. Xerox represented that its PA personnel includes “Medically knowledgeable PA Specialists who analyze and process requests.” Xerox further represented that medical necessity reviews were performed only by medically qualified personnel.”
Years for the State to take action
Two years later, after approving the contract, HHSC finally gets confirmation the dental specialists have no training.
Now, three years later than that, the State takes action against Xerox.