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MyView: Embracing program integrity

April 15, 2019

By Rhonda Switzer-Nadasdi, D.M.D.

Photo of Dr. Switzer Nadasdi
Rhonda Switzer-Nadasdi, D.M.D.
I love it when I see our new ADA vision statement "empowering dental professionals to achieve optimal health for all" being embraced. One way to accomplish this is by participating in Medicaid. As an incentive, the ADA's Medicaid Provider Reference Guide and Advocacy Toolkit serves to educate providers and encourages greater collaboration with state Medicaid agencies.1 Practical Medicaid reform must improve enrollee access, quality of care, reduce administrative burdens, be cost effective and prove beneficial for dentists, patients, the state Medicaid agency and taxpayers. Often, this entails increasing provider reimbursement rates, which is not always feasible, but removing disincentives can be equally as valuable.  

To this end, the ADA's Council on Advocacy for Access and Prevention's Medicaid Provider Advisory Committee seeks to reduce the administrative burdens and perceived risks associated with provider participation in Medicaid. This article explores four practical ADA resolutions that could be a game-changers.

The 2015 ADA House of Delegates passed two actions that laid a solid foundation for states to support strong dental Medicaid programs (Trans: 2015.275):
1) The American Dental Association encourages all state dental associations to work with their state Medicaid agency in hiring a chief Medicaid dental officer, who is a member of organized dentistry.

2) The American Dental Association encourages all state dental associations to actively participate in the establishment or continuation of an existing Medicaid dental advisory committee that is recognized by the state Medicaid agency as the professional body to provide recommendations on Medicaid dental issues.

Tennessee is one of about a dozen Medicaid managed-care states that have carved out their dental program, meaning that the state contracts directly with a dental benefits manager for administering dental benefits versus contracting with a medical managed-care company that subcontracts for dental services. Benefits of a dental carve out include greater dental benefits manager accountability due to a dedicated dental budget and detailed dental contract provisions, such as scope of services, enrollee access, dental network adequacy, utilization management, utilization review, quality of care and oral disease prevention, program integrity, claims processing, adjudication and payment, enrollee outreach and education. There are also liquidated damages assessed to hold the dental benefit manager's feet to the fire in instances where specific requirements have not been met.  

Tennessee has had a Medicaid chief dental officer, Dr. Jim Gillcrist, for almost 17 years. Dr. Gillcrist is also the TennCare dental director, who has direct oversight of all Medicaid and Children's Health Insurance Program dental contracts. He understands dentistry, has treated patients, has a specialty degree in dental public health, and is an ADA member dentist. Dr. Gillcrist is a dedicated public servant who understands how to improve the oral health of underserved populations through thoughtful collaboration with others. A chief dental officer establishes the overall vision for the Medicaid dental program, which is moving from dental treatment to oral health prevention and value-based care.

Tennessee utilizes a Medicaid Dental Advisory Committee, which serves as a forum for participating dentists to bring forth their concerns. It allows for brainstorming, problem solving, sharing of ideas, enhanced communication, state updates and professional input for improving enrollee utilization and quality of care. Although the committee recommendations are not binding on the state, the majority of its recommendations have been adopted, which improved quality of care and cost efficiency.  

Committee members include representatives from multiple dental associations; major dental specialties; the Tennessee Dental Hygienist Association; dentists from all three grand divisions of the state; colleges of dentistry (University of Tennessee and Meharry Medical College); the Tennessee Primary Care Association (representing federally qualified health centers); the state Department of Health; faith-based charitable dental care; and the dental benefits manager. This committee seeks to increase the use of proven oral disease prevention modalities, medical necessity criteria and periodicity scheduling. Some states include a consumer representative. In Tennessee, this committee is weighted more towards representing dental professionals, rather than member advocacy or politically oriented actions.

The 2017 and 2018 ADA House of Delegates passed subsequent actions that encouraged fairness and equity within audits conducted via the state Medicaid agency itself or through a contracted entity (Resolutions 33H-2017 and 69H-2018).

3) The American Dental Association encourages all state dental associations to work with their respective state Medicaid agency to ensure that Medicaid dental audits be conducted by dentists who have similar educational backgrounds and credentials as the dentists being audited, as well as being licensed within the state in which the audit is being conducted.

4) The American Dental Association encourages all state dental associations to work with their respective state Medicaid agency to create a dental peer review committee, made up of licensed current Medicaid providers who provide expert consultation on issues brought to them by the state Medicaid agency and/or third party payers.

In Tennessee, the Medicaid dental contract requires, as part of the utilization review process, that the dental benefits manager have a peer review committee made up of licensed dentists in good standing with the Tennessee Board of Dentistry, who are well-versed in TennCare's medical necessity guidelines. I serve on the dental benefits manager dental peer review committee along with other Tennessee general dentists and specialists, all of whom are Medicaid providers themselves.

This peer review committee reviews complaints arising from patients, dental staff or other providers; however, the vast majority of reviews concern dentists whose treatment practices deviate significantly from other in-network dentists performing similar procedures based on dental specialty and where chart audits reveal suspected fraud or abuse. Close professional scrutiny by the committee in such instances is a serious undertaking. Everything is conducted with the utmost professionalism and confidentiality. The committee is not informed of the names of the dentists or where they practice.  

The committee reviews quality of care concerns, lack of compliance with the office reference manual policies, and/or medical necessity criteria and delivers its consensus findings in writing. Its recommendations may necessitate review of additional enrollee case files, site visits, provider and staff education, recoupment of provider payments and/or any combination of these actions.  

In egregious cases, the committee has recommended the removal of a provider from the dental benefit manager's network. Usually education is enough to modify errant behavior and re-establish the dentist as a beneficial member of the dental provider network. Its findings and recommendations are also shared with TennCare's Program Integrity Unit.

Though these actions have helped improve the oral health of Medicaid-eligible individuals, there remains an ongoing challenge of recruiting and retaining enough dentists to provide care. It would help if participating dentists know when questions about their practice arise and that their unique circumstances be evaluated in a fair and equitable manner by peers.
I have served on my state dental association and our state Medicaid program peer review committees.  They are distinct entities having entirely different rationale and standards. The TDA peer review committee mediates patients and dentists to satisfy dissatisfied customers.

The dental benefits manager peer review committee seeks to ensure that participating dentists are following policies and medical necessity criteria in the Medicaid reference manual, so that enrollees receive appropriate care. Dentists voluntarily agree to follow these rules upon signing their Medicaid provider agreements.  

Improving Medicaid necessitates collaboration among many stakeholders. To be leaders and advocates for oral health, dentists must work closely with these stakeholders to implement practical measures that everyone can benefit from, such as those presented in these four ADA resolutions.


Dr. Switzer-Nadasdi is a member of the ADA Foundation Board of Directors, former member of the Council on Advocacy for Access and Prevention, a current ADA delegate, the past president of the Nashville Dental Society and chairs her state association access committee.