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Association advocates for Medicaid provider audit guidelines

October 23, 2020

By David Burger

The Association encourages state dental associations to work with their respective state Medicaid agency to adopt guidelines for Medicaid Dental Reviews, according to a resolution approved by the ADA House of Delegates in October.

Resolution 25H-2020 urges auditors to follow specified guidelines outlined in the resolution when auditing Medicaid providers.

The resolution is personal for Jessica Meeske, D.D.S., chair of the Council on Advocacy for Access and Prevention, which submitted the resolution.

It all comes down to fairness, Dr. Meeske said.

 Jessica Meeske
Dr. Meeske
As a Nebraska-based pediatric dentist, she believes that many dentists decline to participate as Medicaid providers due to frustration associated with perceived unfairness and inequity within Medicaid reviews and audits conducted by a variety of governmental agencies or their contractual representatives.

According to the resolution, auditors/reviewers shall demonstrate adherence, not only to individual state board regulations and requirements, but also an understanding, acceptance and adherence to Medicaid state guidelines and specific specialty guidelines as applicable.

In addition, the auditor/reviewer shall demonstrate experience in treatment-planning of specific patient demographic groups and/or unique care delivery sites that influence treatment-planning being reviewed.

The resolution recommends that entities, which conduct Medicaid Dental reviews and audits, utilize auditors and reviewers who:

• Have a current active license to practice dentistry in the state where audited treatment has been rendered and be available to present their findings.
• Are of the same specialty (or equivalent education) as the dentist being audited.
• Document and reference the guidelines of an appropriate dental or specialty organization as the basis for their findings, including the definition of medical necessity being used within the review.
• Have a history of treating Medicaid recipients in the state in which the audited dentist practices.
• Have experience treating patients in a similar care delivery setting as the dentist being audited, such as a hospital, surgery center or school-based setting, especially if a significant portion of the audit targets such venues.

These entities shall be expected to conduct the review and audit in an efficient and expeditious manner, including stating a reasonable period of time in which an audit can proceed before dismissal can be sought and defining the reasonable use of extrapolation in the initial audit request.

While it is reasonable to expect a degree of oversight when public resources are being utilized to improve the health of individuals, there should be clear and transparent guidelines that all parties acknowledge and agree to abide by as part of participation in the program, Dr. Meeske said. Doing so could serve to attract new Medicaid providers and curb attrition of existing participants.

The situation prompted then-ADA President Chad P. Gehani, D.D.S., to send a letter to the director of the Division of Medicaid and Long-Term Care Nebraska Division of Health and Human Services in November 2019. The letter, also signed by the presidents of the Nebraska Dental Association, American Academy of Pediatric Dentistry and Nebraska Society of Pediatric Dentistry, said they were troubled by the growing number of Medicaid pediatric dental audits in Nebraska that were harming children’s access to oral care.

In the letter, 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 said they were especially 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.”