As a result, more orthodontic PAs were approved, which has resulted in the State of Texas spending excessive dollars for orthodontic procedures
Austin, TX (PRWEB) December 19, 2013
Texas Dentists for Medicaid Reform has released on their website an August 2012 audit conducted by the Texas HHSC Office of the Inspector General on the Texas Medicaid and Healthcare Partnership, the state's private contractor that was responsible for approving hundreds of millions of dollars of Medicaid orthodontic pre-approval requests from 2004 to 2012. TMHP is basically Affiliated Computer Services (ACS), a division of Xerox.
This past February TDMR placed online an earlier OIG audit of the same TMHP pre-approval process done in 2008 which had disclosed a number of deficiencies.
The 2012 audit and its results were first announced by Douglas Wilson, HHSC Inspector General, in legislative testimony before the House Committee on Public Health on October 15th, 2012. Slides from that presentation are available on the HHSC website.
Pg 16 of the slide presentation states:
"Follow-up audit of TMHP was conducted in conjunction with the U.S. Department of Health and Human Services’ (HHS) review. Internal Control Report was issued August 1, 2012, and significant findings included:
- TMHP is not hiring medically knowledgeable personnel to process dental prior authorization requests as contractually required
- The dental director is not approving all orthodontic prior authorization requests
- TMHP’s Quality Assurance Review tool does not address medical necessity
- TMHP is approving multiple prior authorization requests for the same client and the same service"
However, per the audit document, TMHP disputed each of the findings.
Excerpts from the audit document states:
National Heritage Insurance Corporation (NHIC) was responsible for reviewing PA [prior authorization] requests prior to TMHP assuming the contract. NHIC had a process whereby an NHIC Dentist/Orthodontist reviewed all Dental/Orthodontist Prior Authorization requests submitted. When TMHP took over the contract, this process changed. Under TMHP’s process, providers were required to submit Dental Orthodontic PA requests in the same manner as the NHIC contract required. However, TMHP did not require the Dental Director to review all Dental Orthodontic PA requests. Under the TMHP process, the Dental Orthodontic PA specialists reviewed provider/client eligibility, the supporting documentation, and if the Handicapping Labio-Lingual Deviation (HLD) score sheet equaled 26 or above. If these requirements were met, the claim was deemed medically necessary and approved. This contributed too [sic] millions being expended on Medicaid Orthodontics in 2010.
"Finding 1 – TMHP is not hiring medically knowledgeable personnel
TMHP is not hiring medically knowledgeable personnel to process dental PA requests as required by the contract… As a result, more orthodontic PAs were approved, which has resulted in the State of Texas spending excessive dollars for orthodontic procedures…The duty is on TMHP to comply with all laws and regulations. The law requires that a dentist make the determination of medical necessity. The prior claims administrator complied with the law and the prior claims administrator worked with TMHP for a transition period. HHSC indicates that it has repeatedly attempted to work with TMHP to ensure compliance with the contract requirements.
"Finding 2 – Dental Director is not approving all orthodontic PAs
…Through dialogue with TMHP staff and in reading the audit and SAR [State Action Request] responses, HHSC staff believed TMHP was applying the approved medical policy requirements and criteria in making decision to approve or deny the orthodontic PAs. It now appears that TMHP staff never reviewed the diagnostic tools required to be submitted that were necessary to enable TMHP to make a determination of medical necessity. It also appears that the diagnostic tools were never imaged and that some were destroyed.
"TMHP further states that they did not receive any additional direction from HHSC as a result of the audit  or the findings to change the prior authorization process. HHSC disagrees with this statement. HHSC began meeting with TMHP in April 2009 to address the audit and issues related to non-compliance with the contract. TMHP has repeatedly misled HHSC as to what has been occurring."
For more information, see the full article on the TDMR website.