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Dental groups urge Nebraska Medicaid office to halt, overhaul pediatric dental audits

Auditors ignore caries risk assessment, reject AAPD clinical recommendations, letter says

November 08, 2019

By Jennifer Garvin

The American Academy of Pediatric Dentistry, American Dental Association, Nebraska Society of Pediatric Dentistry and Nebraska Dental Association are troubled by the growing number of Medicaid pediatric dental audits in Nebraska that are harming children’s access to oral care, the organizations told the state’s Medicaid agency in a Nov. 6 letter.

In the letter to Matthew Van Patton, director of the Nebraska Division of Health and Human Services’ Division of Medicaid and Long-Term Care, the four organizations said that the audits have led to “unfortunate outcomes detrimental to the program’s goal of improving oral health access for children of low-income families.”

The dental groups also said they are concerned about the 2018 audits of several Nebraska pediatric dentists that took place under AdvanceMed, a Unified Program Integrity Contractor for the region’s Centers for Medicare & Medicaid Services. The organizations said they believe that dental auditors were not basing their reviews on AAPD’s accepted clinical recommendations and were “second-guessing clinical decision-making by pediatric dentists absent appropriate peer review by a dentist with equivalent educational training.”

The organizations added they are especially concerned that the audits questioned the use of stainless steel crowns in children at high caries risk, many with signs of severe decay on multiple teeth, and requested significant refund of payments for alleged inappropriate treatment. They also noted that in AdvanceMed’s November 2018 correspondence to one pediatric dentist Medicaid provider, the contractor specifically stated that AAPD’s clinical recommendations were “irrelevant” to their audit findings.

“In the first audit case considered, we understand the auditor disagreed with the pediatric dentist’s choice of restoration in many cases because the ‘least costly restoration’ was not chosen,” the organizations said. “However, the treating dentist did not address the disease in isolation; this dentist considered the least costly option in the context of the life of the tooth, the risk factors for future disease and the life of the child.”

“Stainless steel crowns are far more durable than other types of restorations for primary teeth. The auditor only considered the least costly option at the point of service,” the letter continued. “Ignoring the caries risk assessment of a child was egregious on the part of the auditor. There was no question that restorations were needed. In considering which restorative treatment was best for a child, the pediatric dentist made the right decision based on accepted professional clinical recommendations.”

The organizations also pointed out that the official Centers for Medicare & Medicaid Services Guide to Children’s Care in Medicaid indicates that children who are caries-active or at high risk for caries “may require more frequent diagnostic and preventive procedures,” which would include stainless steel crowns.

“Our organizations are strongly committed to effective program integrity efforts and promoting children’s access to oral health care via the Medicaid program,” they wrote. “However, we believe it is counterproductive and damaging to the Medicaid dental program to have auditors second guess the clinical judgment of a pediatric dentist who is adhering to clinical recommendations developed by their professional association.”

The dental groups also said they believe the lack of “appropriate peer review by a pediatric dentist” experienced in treating high caries risk children such as those in Medicaid, is “fundamentally unfair and a denial of due process.” They noted that since pediatric dentistry is a recognized dental specialty, a pediatric dentist should be reviewed by a fellow pediatric dentist and not a general dentist who does not treat Medicaid patients and is unaware of AAPD’s clinical recommendations.

“In the first pediatric dentist audit case it was clearly established in the appeal hearing that AAPD clinical recommendations were ignored by the auditor,” the dental groups wrote.

They noted that after incurring a significant amount of legal fees in that case, the pediatric dentist eventually gave up the appeal and settled the case for $50,000 and stopped being a Medicaid provider.

“The end result is that the audit has harmed children’s access to oral health care while recovering a pittance of overall Medicaid spending in the state,” the organizations wrote. “In the administrative hearing of this pediatric dentist’s appeal, the state Medicaid agency was ill-prepared and ill-informed, but still could not be persuaded to drop the case or settle for a modest amount. This particular pediatric dentist has lost faith in the state Medicaid agency and will not be a positive spokesperson to other established dentists or residents-in-training to consider participating as a Medicaid provider. This is an unintended consequence that is a counter-intuitive outcome for a program meant to help the state’s poorest children obtain oral health care.”

The dental organizations also detailed similar audits of pediatric dentists in Nebraska and stressed that “misguided audits like these only hurt children’s access to dental care,” endanger the viability of Medicaid provider networks, and put the state’s dental educators in a difficult position since they teach the AAPD clinical recommendations. Furthermore, they noted, the Nebraska Board of Dentistry looks at the AAPD’s clinical recommendations to determine the standard of oral health care for children.

“This puts a pediatric dentist in an impossible situation of being unable to satisfy contradictory treatment recommendations from the state Medicaid agency and the Board of Dentistry,” the dental groups said.

The AAPD, ADA, Nebraska Society of Pediatric Dentistry and Nebraska Dental Association concluded by asking the Nebraska Division of Medicaid and Long-Term Care to halt the audits and require all future Medicaid dental auditors to utilize dental profession clinical guidelines, best practices and policies of the appropriate specialty organization, such as the AAPD and ADA. They would also like the contracted auditors to utilize licensed dentists of equivalent education and training as the dentists being audited and to have experience in treating Medicaid patients.

The Nebraska dental Medicaid letter is available on the ADA website.