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Medicaid RAC audits

‘Will dentists simply opt out?’

July 15, 2014

by Craig Palmer

image of Dr. Meeske on the senate panel
Dr. Meeske: Flanked by durable medical equipment and Medicare contractor representatives, Dr. Jessica Meeske (center) offers testimony on Nebraska dentists' concerns with dental Medicaid RAC audits. Senate photo
Hastings, Neb.—
Having brought Medicaid RAC audits of dental practices to Congress' attention, "we will have to continue to be at the table to tell our story," Dr. Jessica Meeske said after testifying July 9 at a U.S. Senate-convened roundtable discussion on government audits.

"Dentistry is so vastly different from medicine in terms of how we deliver care and our small practice sizes," she said. "Because we are small, RAC audits will affect dental practices in ways that are also different. For example, the majority of dentists have very little understanding of what the different types of audits are and how RAC audits are only one of many kinds of audits.

"We do not have entire departments or even dedicated staff in our practices that devote time and energy to responding to audits. In addition, the federal government is much more focused on improper payments in Medicare. While today we were able to bring the issues of RAC audits within Medicaid to their attention, we will have to continue to be at the table to tell our story."

Dr. Meeske, chair of the Nebraska Dental Association's Medicaid Committee, testified for the ADA at the invitation of the Senate Special Committee on Aging. Although the roundtable discussion focused on Medicare audits, the committee acknowledged growing concerns about Medicaid RAC audits. Dr. Meeske expanded on her testimony at the invitation of the ADA News.

"Where before dental practices could in 'good faith' submit claims to their dental Medicaid programs, believing if their intent was good, their billing practices sound, their care reflecting current clinical standards of care, and following their Medicaid provider manuals, they would not be faced with mass audits, this is no longer the case," she said.

"When auditors are incentivized to 'look hard for ambiguity and unclear language in existing policy' in state Medicaid provider manuals, they can run multiple algorithms and identify 'potential billing inconsistencies' and ask dentists for [repayment]. Many dentists will simply send back the money because it's not worth the headache and stress of appealing the audit."

Unfortunately, many communities will lose outstanding dentists who will simply quit seeing Medicaid patients, Dr. Meeske said. "No one thinks that dentists who abuse the system should not have appropriate consequences. However, for the hard working dentists who have a long history of being good Medicaid providers will Medicaid integrity units crack down so hard that the dentists will simply opt out?

"What auditors and state MIUs don't seem to get is that each dentist is making a decision at a point in time that they believe is in the best interest of their patient as a whole not as one tooth or one surface of decay. In the cases of so many children we see, they have not just complicated dental disease, they often have complicated medical issues, behavior issues and family/social issues that a dentist must take into consideration when designing a prevention plan and treatment plan."

Some families have more than one child, travel long distances and must miss work and school to receive dental care. "We don't ask the parent to bring in each child separately just so we can put compliance with a six-month prophy rule ahead of a child's best interests," Dr. Meeske said. "To the contrary, we have to provide our care in a way that encourages these families to use it because we know if they do we will prevent even greater dental disease and Medicaid expenditures to our state."

In Nebraska, nearly 300 dentists were asked for repayment on every patient seen on less than a six-month recall, she said.

"Dental Medicaid program staff, MIU staff and state dental associations will be better off working together on the front end to improve billing systems," said Dr. Meeske. "I have no doubt that the majority of dentists would welcome suggestions and helpful feedback on how to improve their billing systems. They much better respond to feedback when it's done in a way that is helpful and not punitive."