Medicaid Orthodontists Give Input on Administrative and Payment Changes

Molly PereiraFeatured News

December 21, 2011

The state Medicaid program hosted a full-day stakeholder retreat on Dec. 7 to gather feedback from dentists about possible administrative changes to the Medicaid orthodontic benefit. The discussion addressed both comprehensive and interceptive orthodontia. Medicaid is considering clarifying the prior authorization process for orthodontics through the addition of transparent scoring criteria. There has also been discussion of revising payment protocols for orthodontic services.

Stakeholders present were interested in the California modification to the Handicapping Labio-Lingual Deviation (HLD) index as a starting point for scoring comprehensive orthodontics. Stakeholders were encouraged to review the training videos for California’s scoring system, and to offer feedback on where additional clarity is needed. Stakeholders discussed whether orthodontists should be required to complete a similar scoring training program as part of their Medicaid credentialing, prior to being eligible to submit orthodontic cases for approval. A disciplinary system could be established to address those who inflate scores, employing retraining protocols followed by termination of the provider from the Medicaid program.

For interceptive orthodontics, the current prior authorization form was recommended as a starting point. Practitioners recommended that the form be modified to include a description of the treatment goal and treatment plan. Stakeholders provided input on what interceptive services should be reimbursed by Medicaid. The group emphasized the importance of maintaining reimbursement for some interceptive services, as they can result in cost savings through preventing the need for some comprehensive orthodontics. The group also discussed whether pediatric dentists who can demonstrate sufficient orthodontic training should be allowed to offer limited interceptive services, such as correction of a single tooth crossbite and certain ectopic eruptions, perhaps at a lower reimbursement level. Discussion on this topic addressed convenience for patients, quality of care, continuity of care, and private insurance market practices. The group discussed establishing a time gap between approval of interceptive services and comprehensive orthodontics, as well as demonstration of results (or explanation of unexpected outcomes) from the interceptive treatment plan prior to approval of comprehensive orthodontic treatment.

Regarding payment structure, the stakeholders preferred maintaining the existing payment system, which provides up-front reimbursement for the full course of orthodontic treatment as an incentive to encourage provider participation. However, Medicaid indicated that this payment structure poses some challenges both politically and administratively. Though not preferred, stakeholders recommended a system of three payments as an alternative, with the largest payment occurring at the onset of treatment, the second largest payment after 10 months of treatment and a small final payment at debonding. Addressing patient eligibility changes was a concern in moving to a system of multiple payments. The group also discussed the possibility of outsourcing the Medicaid orthodontic program to a third-party administrator. Finally, stakeholders discussed some patient accountability structures, such as limits on the number of times a patient can apply for orthodontic services within a specified time frame and reimbursement for orthodontic records only if the patient is approved for an orthodontic service (if not approved, the patient would be responsible for payment for the records).

Medicaid will consider the suggestions and input from the stakeholders forum, and ultimately propose formal changes for public review. The CDA will be closely tracking this process and will continue to inform members of the opportunity for future input.