Pediatric Restorative Benefits: Potential for Fraud & Abuse · PDF filePediatric Restorative Benefits: Potential for Fraud & Abuse . 2 ... Doral Dental Founder: ... 300 Aspen Dental

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Craig Kasten Wednesday September 17, 2014 1:30pm

Part 2

The Medicaid-Commercial Spectrum, Media Reports of Abuse, U.S.

Senate Study, Quest for the Facts and a Plan of Action

Pediatric Restorative Benefits:

Potential for Fraud & Abuse

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Insights learned over the past two decades

Introduction & Review of Part 1

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Sole Focus = Medicaid Beneficiaries

Craig Kasten: Industry Founder A B O U T

Founder: Wonderbox Technologies 1993

Founder: Doral Dental 1994

Founder: Scion Dental 2009

Dental & Vision Cloud Computing Services Headquarters in Wisconsin

Combined, these two companies today arrange for the delivery of dental benefits to over 25 million children nationwide

© 2014 Scion Dental, Inc. CONFIDENTIAL & PROPRIETARY

http://www.google.com/url?sa=i&rct=j&q=doral cigarettes&source=images&cd=&cad=rja&docid=yvQOmhHxvGdo-M&tbnid=mTG_6QY7JawETM:&ved=0CAUQjRw&url=http://cigarettecoups.com/doral-cigarette-coupons.html&ei=NPUsUojiE4OBygGnroDACA&bvm=bv.51773540,d.aWc&psig=AFQjCNGdG2KklIjjKvmGLT7AGBirJLOEJQ&ust=1378764459481779

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A tale of two cities

Commercial Dental vs.

Medicaid Dental


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Medicaid Dental Commercial Dental

Patient Eligibility Verification

Always verified before patient

appointments

50% of member calls are “find

a provider”

Rarely verified before patient

appointments


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Benefit Plan Design

Plan designs seldom change

No deductibles

No coinsurance or copayments

No annual maximums

Plan designs often change

Deductibles

Coinsurance or copayments

Annual maximums


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Patient Scheduling

Double booking practiced…

50% of appointments missed

Double booking is not an

acceptable practice


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Dentist Participation

~15% of all dentists participate

(varies by state based on fees)

~100% of all dentists see

commercial patients


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Patient Age

~100% of patients age 21 and

under (limited adult coverage

varies by state)

~25% of patients age 21 and

under


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Reimbursement Variance by State

Fees and aggregate per capita

spending vary dramatically by

state

Range of $8 pmpm to $30

pmpm

Relatively consistent spending

across regions


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Patient Access to Services

Top priority

Complex reporting

requirements with significant

financial penalties for failure to

attain targeted access levels

Seldom (never) mentioned as

a top concern with financial

benefit accruing to insurer or

employer from lower service

utilization levels © 2014 Scion Dental, Inc. CONFIDENTIAL & PROPRIETARY

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Dental Plan Funding & Billing

100% government funded (split

between Federal and State)

No client billing requirements

No broker commissions

100% funded by private sector

sources, extensive effort to

bill, and reconcile payments

Broker commissions common


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Other Differentiating Patient Attributes M E D I C A I D V S . C O M M E R C I A L

Transient residency

Language barriers

Patient transportation

options

Waiting room requirements

Oral hygiene training

Urban/Rural concentration


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Commercial dental insurers fail miserably when

attempting to manage Medicaid benefits due to:

1. Inadequate systems to address Medicaid priorities, manage call volumes and address unique reporting requirements

2. Inappropriate business model

Common Result M E D I C A I D V S . C O M M E R C I A L


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A vulnerable population with no out of pocket charges to constrain potential patient abuse

Pediatric Overtreatment: Widely

Reported and Studied


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News and Media Reports R E P O R T E D & S T U D I E D


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News and Media Reports R E P O R T E D & S T U D I E D


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Senate Investigation R E P O R T E D & S T U D I E D

Church Street Health Management

70 Small Smiles dental clinics in 22 states and the District of Columbia

130 Kool Smiles clinics in 15 states and the District of Columbia

Operates mobile school-based clinics in several states

300 clinics in 18 states

300 Aspen Dental clinics in 22 states

NCDR

ReachOut Healthcare America

Heartland Dental Care

Aspen Dental Management


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Recommendations

1. Exclude these two organizations from Medicaid participation

2. Have States enforce laws to prohibit corporate practice of dentistry

3. Consider the licensure of mid-level providers


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ADA Response:

“Such conduct is inexcusable, and should be prosecuted vigorously. However, equally disturbing is the broad brush that implicates a whole class of practice models rather than focusing on the actual offenders.”


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Intriguing Senate Panel Question… R E P O R T E D & S T U D I E D

If the fees are so low, why are there

millionaire dentists in Medicaid?


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Recent Updates


23 Medicaid Expansion - 133% of Fed Poverty Level R E C E N T U P D A T E S

Table 1: Medicaid and CHIP: May and June 2014 Preliminary Monthly Enrollment


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Section 6411 of the Patient Protection and Affordable Care

Act (ACA) directs states to establish programs in which they

will contract with one or more Recovery Audit Contractors

(RAC), to reduce improper payments.

Era of Accountability:

RAC Audits


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How does it work? R A C A U D I T S

Each RAC contractor uses its own proprietary methodologies developed in compliance with CMS rules and regulations. RACs will report potential fraud to CMS and potential quality issues to the state or territory Quality Improvement Organization (QIO).


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What do the facts

indicate? Aggregate per capita

cost by age

Extreme patient cases

“To those who should

be concerned…….”

Let’s Dig a Bit Further:

Proprietary Research


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Aggregate Market Data P R O P R I E T A R Y R E S E A R C H

All Regions


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Aggregate Market Data (continued)

P R O P R I E T A R Y R E S E A R C H

All Regions


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Eruption/Exfoliation P R O P R I E T A R Y R E S E A R C H


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Eruption/Exfoliation (continued)



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Proprietary Research:

Extreme Patient Cases

Pulled from internal database


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Extreme Patient Cases P R O P R I E T A R Y R E S E A R C H

18 crowns before age 4 9 teeth crowned more than once

Patient A: 3 years old

$7,000 in restorative

services before age 4


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Extreme Patient Cases (continued)


16 teeth extracted during one visit • Performed in a pediatric office • No general anesthesia

Remaining teeth extracted within 5 months All teeth removed by age 2

Patient B: 1 years old

$3,900 in one dental visit


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Patient C: 1 years old

$4,000 in one pediatric dental visit

26 procedures on same day, including: 10 Extractions 8 Crowns 1 Therapeutic Pulpotomy


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Patient D: 5 years old

$6,700 in dental services in one visit

All services received on same day 19 Crowns 10 Pulp caps 1 Pulpal therapy 3 Pulpotomies 1 Extraction


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Recent Extreme Patient Cases P R O P R I E T A R Y R E S E A R C H

Patient A: 2 years old

$7,700 in dental services

in one visit

All services received on same day 16 Root Canals 16 Crowns No anesthesia billed


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Recent Extreme Patient Cases (continued)


Patient B: 2 years old


All services received on same day 16 Extractions Remaining 4 teeth received both a

Pulpotomy and SS Crown Remaining teeth: not upper/lower

corresponding


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Patient C: 5 years old


All services received on same day All 20 teeth received a Pulpotomy and a Crown 4.5 hours of general anesthesia

CONFIDENTIAL & PROPRIETARY © 2014 Scion Dental, Inc.

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All services received on same day 19 Crowns 10 Pulp caps 1 Pulpal therapy 3 Pulpotomies 1 Extraction

Patient D: 5 years old



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All services received on same day 20 Surgical Extractions 4 Alveoloplasty 10 Other Surgical Procedures

Patient E: 3 years old

$10,600 in dental services

in one visit


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To those who should be

concerned…


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Fraud and/or abuse of young patients enrolled in

Medicaid is a continuing problem that needs to be

addressed.

Many dentists & clinics in

Medicaid do a great job


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Education On-line Provider Profiling - Early Identification - Age Banded

Industry Collaboration Institute for Research & Policy Formation

ADA

Technology-Aided Solutions New Outlier Sanction Program

New Claim Edits based on Tooth Properties

Eruption Date Variance from DOS

Exfoliation Date Variance from DOS

Mobile phone patient outreach © 2014 Scion Dental, Inc. CONFIDENTIAL & PROPRIETARY

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Age Banded Real Time Provider Profiling P R O V I D E R E D U C A T I O N


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Provider Education P R O V I D E R W E B P O R T A L

Custom reports allow provider to compare utilization vs. peers

Provider Web Portal


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Sanction

Program

P R O P R I E T A R Y Enterprise

System

Statistical Analysis/

Provider Profiling Hotline Tips

Client Notification

No Action Required

Provider Education Letter

Severe Allegation

Suspension or Termination**

Revised Behavior

Clinical Review (Chart Audit)

Able to Chart Audit

Alternative Reimbursement

Methods**

Additional Authorization or Documentation Requirements**

Aberrant Results in

Chart Audit

No

No

No

Yes

No

Yes

Yes

** Dependent on severity of aberrant behavior

Yes

Client Discretion


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Overutilization of CDT code D4341

Initial Intervention: Require

authorization

Behavior revised

Provider A – General Dentist

After sanction, CDT code D4355 is overutilized

Future intervention: Require authorization

on all periodontic codes

Sanction Program- In Effect P R O P R I E T A R Y


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Industry Collaboration

Institute for Research & Policy Formation

ADA

NADP


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Thank you for attending

We hope you find this information useful

We welcome your questions and comments

http://nadpconverge.org/evaluations

http://nadpconverge.org/evaluations

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Pediatric Restorative Benefits: Potential for Fraud & Abuse · PDF filePediatric Restorative Benefits: Potential for Fraud & Abuse . 2 ... Doral Dental Founder: ... 300 Aspen Dental