Letters: Response to FQHC letter
January 23, 2017
The National Network for Oral Health Access believes we need to clarify some misconceptions published in a letter featured in the ADA News in the Oct. 17 issue from Dr. Stephen L. Kirkpatrick titled “FQHCs and Numbers.”
The author correctly states that reimbursement levels for private practices in the majority of state Medicaid programs are lower than dentists’ usual and customary fees.
We can also agree that many may not understand how health centers are reimbursed or, more importantly, why it is necessary.
It is essential to note that while all states are required to provide dental care for children, dental benefits for adults are still optional. Only 18 states, including Washington, D.C., have relatively comprehensive benefits, 16 states have limited coverage, 12 states provide only emergency benefits, and five states provide no coverage at all.
Although the reimbursement mechanism for individual state Medicaid programs varies, the majority of federally qualified health centers are reimbursed on a set global payment or encounter rate. Contrary to what Dr. Kirkpatrick asserts, there are no states where an FQHC may receive both a fee-for-service dental payment and their encounter rate. Each health center’s reimbursement is individualized based on actual annualized costs and is not designed to create a profit.
The national average for encounter rates is $182.60. Medicaid reimburses one dental encounter per day regardless of whether the patient sees more than one dental provider in the same day, and in many states, often encompasses visits to other clinical departments as well.
So, while there are times the actual fee charged for a service is less than the encounter rate, there are many instances where the global reimbursement received is less than the cost for care rendered. In the end, this should all balance out.
The encounter rate is designed to reimburse the facility for the average of all costs, administrative and clinical, for providing all health care services, not just limited to dental care. This fixed rate is paid for Medicaid beneficiaries with coverage for eligible dental services. Most other health center patients pay for dental services based on an income-based sliding scale and often merely a nominal fee, regardless of what services are performed.
The National Network for Oral Health Access considers it unethical for a health center to divide a treatment plan into multiple visits solely to increase reimbursement rather than meet the clinical needs of the patient, the same way over-treatment with fee-for-service reimbursement in order to maximize revenue is also unethical in the private sector. These intentional fiscal abuses occur in only a minority of both types of practices and the National Network for Oral Health Access believes that the vast majority of health centers and private practitioners are ethical providers who have their patients’ best interests in mind.
In 2015, FQHCs were only able to take care of just over 5 million dental patients. There are an estimated 45 million individuals living in dental health shortage areas, and over 130 million without dental insurance in the United States. Health centers simply cannot do it alone and require the help of colleagues in private practice to address the needs of the underserved in rural, suburban and urban communities. We agree with Dr. Kirkpatrick that in many states Medicaid reimbursement rates for private dentists discourage dentists from participating in the program, but we know that it is not realistic to expect that public health programs match fees in private practice.
Many private providers find ways to participate in other reduced fee-for-service programs without severe impact to their bottom line.
We strongly applaud those private dentists who dedicate a portion of their practices to the less fortunate, and encourage more to do so.
The National Network for Oral Health Access’ desire is for the entire dental community to work together to advocate for improved access to oral health care in all states, and we believe it is important that we all have accurate information to do so.
Janet Bozzone, D.M.D.
President, National Network for Oral Health Access