“Lack of dental insurance is a driving factor of wide health disparities that exist across underserved and marginalized communities,” said Myechia Minter-Jordan, MD, MBA, president and CEO of CareQuest Institute for Oral Health. “Recent research has shown that increasing dental coverage is one policy lever that can make a difference in more equitable access to dental care. Our hope is that this new tool raises awareness for administrators, policymakers, and advocates so they can design and strengthen dental benefits in Medicaid that meet the oral health needs of millions of adults across the country who do not currently have access to this critical care.”

Four leading oral health and health policy organizations built this new Coverage Checker to help stakeholders gain a deeper understanding of current benefits and clear guidance on ways to improve coverage.

The organizations first created an updated evidence-based definition of an extensive Medicaid adult dental benefit and then developed a consensus-driven assessment survey, completed by state dental directors, to collect detailed information about adult dental benefits offered through the Medicaid program in each state.

“The Coverage Checker allows us to evaluate Medicaid programs based on very specific types of dental care services covered by the program as well as dollar annual limits. This is a huge step forward in understanding the policy landscape in oral health,” said Marko Vujicic, PhD, chief economist and vice president of the ADA Health Policy Institute.

The Coverage Checker looks at coverage of specific procedures and services, including allowed frequency, in eight service categories that are most commonly reimbursed by employer-based dental benefit plans and are critical to maintaining lifelong oral health.

“Oral health is critical to overall health and there are significant disparities for those who do not have access to dental services,” said Hemi Tewarson, NASHP’s president and executive director. “This tool gives a more complete picture of dental coverage across the country providing state leaders with data to help inform policy decisions and innovation.”

Medicaid is a key source of health care coverage for more than 80 million people in the United States. Although states are required to provide comprehensive dental benefits for children covered by Medicaid and the Children’s Health Insurance Program (CHIP), dental coverage for adult Medicaid beneficiaries is optional for states.

While most states provide at least emergency/urgent dental benefits (defined differently by states) for adults, nearly one-third of all states do not provide dental care beyond emergency procedures. According to new data from CareQuest Institute’s second annual State of Oral Health Equity in America survey, 77 million adults in the US do not have dental insurance.

Recent studies reveal the following benefits of comprehensive Medicaid coverage:

• Increased access to dental care can lead to lower medical care costs among individuals who are pregnant or who have chronic conditions such as diabetes and heart disease.
• Dental coverage significantly reduces costly emergency department (ED) visits for dental conditions. Dental-related ED visits nationwide cost an estimated $2.1 billion per year, but nearly 79% of those visits could’ve been addressed in a dental office, saving up to $1.7 billion per year.
• Children whose parents have Medicaid dental coverage are more likely to have had a dental visit in the past year and less likely to have deferred dental care.
• Adults who obtain dental coverage through Medicaid report improved oral health and employability.

Visit the CareQuest Institute website to access the new Medicaid Adult Dental Coverage Checker.

About CareQuest Institute for Oral Health

CareQuest Institute for Oral Health is a national nonprofit championing a more equitable future where every person can reach their full potential through excellent health. We do this through our work in grantmaking, research, health improvement programs, policy and advocacy, and education as well as our leadership in dental benefits and innovation advancements.

We collaborate with thought leaders, health care providers, patients, and local, state, and federal stakeholders, to accelerate oral health care transformation and create a system designed for everyone.

To learn more, visit carequest.org and follow us on Twitter, LinkedIn, Facebook, and Instagram.

FEATURED IMAGE CREDIT: Reto Gerber from Pixabay.

Healthcare fraud, including fraud involving dental practices, is a top priority of the False Claims Act enforcement efforts of the US Department of Justice (DOJ).

Over a recent four-year period, the government recovered $11.4 billion in fraud prosecutions, with 80% of that tied to health programs such as Medicare, Medicaid, TRICARE, Veterans Health, Federal Employees Health Benefits, and the like.

Whistleblowers, or individuals who reported the fraud to the government, received more than $1.54 billion in reward payments.

Dental services are required for most Medicaid recipients under the age of 21, which include diagnostic, preventative, or corrective procedures such as treatment of teeth, oral disease, injury, or impairment.

But from time to time, the US Department of Health and Human Services Office of Inspector General has expressed concern that some dental providers may be inappropriately billing the government for services.

Who Can Be a Whistleblower?

DOJ’s primary route to uncovering fraud is through reporting by individuals with knowledge of the wrongdoing.

When it comes to dental fraud, whistleblowers can include dentists, dental school faculty and students, dental supply dealers and manufacturers, dental hygienists and assistants, practice managers, bookkeepers, lab technicians, patients, or anyone with knowledge or suspicion of fraudulent billings or practices.

What Are the Rewards for Whistleblowers?

If DOJ recovers misspent healthcare money, the individual who brought the fraud to the attention of the government will be entitled to a reward of between 15% and 30% of the amount of misspent funds that the government recovers.

What Are Some Examples of Dental Billing or Dental Fraud Schemes?

In several cases, the United States recovered nearly $60 million for dental fraud. These illegal schemes often target vulnerable low-income children to make millions from unnecessary and unsafe services.

In a 2010 case, dental employees were rewarded more than $2.4 million for blowing the whistle on a dental management company that was found to have provided shoddy or not medically needed dental services to low-income children. The services included pulpotomies (baby root canals), crown placements, administration of anesthesia (including nitrous oxide), extractions, and filling and sealing.

In a 2018 twist on the same theme of exploiting underprivileged children, former employees of a group of dental clinics received $2.4 million for reporting that the clinics and their dental management company pressured and gave financial incentives to dentists to perform unnecessary procedures on young patients covered by Medicaid.   

In a May 2021 case, a whistleblower stood to receive 15% to 25% of a $2.7 million False Claims Act settlement DOJ signed with several dental clinics and their parent health system stemming from allegations that staff used unsterilized handpieces to treat Medicaid patients, in violation of Centers for Disease Control and Prevention rules.

Paying Money to Patient Families or Others to Refer Business to Dentists Is Illegal

Often, violations of the Anti-Kickback Statute or the Stark Law are the basis for whistleblower rewards.

The Anti-Kickback Statute makes it illegal for dental providers to accept bribes, money, or gifts “knowingly and willfully” in return for Medicare, Medicaid, or other federal healthcare program business.

The Stark Law prohibits dentists from referring patients for certain health services paid for by the government to anyone with whom the dentist has a financial relationship.

Both laws aim to ensure that dental decision-making isn’t compromised by improper financial incentives, but, rather, is based on the best interest of the patient.

A 2017 case triggered by an employee of a Texas dental management company involved allegations of kickbacks to Medicaid recipients and marketing companies in exchange for their business. The whistleblower received a reward of $1.521 million.

Why Do the Right Thing?

Once the wrongdoing comes to light, the Department of Health and Human Services Office of Inspector General can require a dental provider to have oversight for several years under what is called a Corporate Integrity Agreement.

Some such agreements require routine auditing or the adoption of procedures and reviews to avoid and promptly detect future misconduct, or to monitor the quality of care and of Medicare or Medicaid claims submission processes. The reporting of dental fraud can thus have a long-term effect of stopping future misconduct.

How Are Whistleblowers Protected Under the Law?

The False Claims Act protects employees from retaliation by their employer. Under the law, an employer may not discharge, demote, suspend, threaten, harass, or discriminate against an employee for speaking up about fraud.

In one case, an orthopedic surgeon whistleblower was paid a $13 million settlement for his claims against the hospital where he worked for retaliation against him after he raised concerns about serious patient safety and disclosures issues.

Ms. Brooker is a partner at Tycko & Zavareei LLP who represents whistleblowers. She was an assistant director at DOJ in the office that supervises False Claims Act whistleblower cases in all 94 federal trial courts. She can be reached for a free consultation at reneebrooker@tzlegal.com, (202) 417-3664, or fraudfighters.net.

Ms. Gunasekera also is a partner at Tycko & Zavareei LLP who represents whistleblowers in all whistleblower programs. She is the former senior counsel for healthcare fraud at DOJ in the office responsible for False Claims Act whistleblower cases in all 94 US District Courts. She can be reached for a free consultation at eva@tzlegal.com, (202) 417-3655, or fraudfighters.net.

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Texas Governor Greg Abbott has signed HB 2056 into law, making teledentistry services available in Texas. The law defines the practice of teledentistry as well as who can perform it. Among other provisions, the law:

• Requires informed consent from the patient
• Mandates confidentiality
• Empowers the Texas Medical Board and State Board of Dental Examiners to enact appropriate rules
• Establishes a standard of care
• Outlines licensing requirements
• Promotes care for underserved areas
• Sets up rules for Medicaid coverage of teledentistry
• Asks for biennial reports on telemedicine’s effectiveness
• Addresses teledentistry’s use in treating children with special needs

DialCare, the telemedicine affiliate company of Careington International Corporation, said it worked with sponsors Sen. Charles Perry (R-Lubbock) and Rep. Stephanie Klick (R-Fort Worth) as well as with lobbyist Andrea McWilliams of McWilliams Governmental Affairs Consultants to ensure HB 2056’s passage.

Noting that the bill passed during a challenging and gridlocked legislative session that had one of the lowest bill passage rates in state history, DialCare said it started working with Perry before the session began and provided significant input for each draft even before the bill was filed.

“I appreciate the stakeholders, including DialCare, coming together to find common ground to support the passage of this important legislation to move Texas forward,” said Klick, who also serves as chair of the House Public Health Committee.

DialCare said that its teledentistry program offers 24/7/365 virtual access to licensed dentists via phone of video consultation for advice and guidance on oral health concerns and second opinions. Texas is now the forty-ninth state where teledentistry services can operate.

“DialCare saw the importance of changing Texas law to allow Texans to access remote dentistry services, so we began working with the Legislature to address this issue more than a year ago,” said Barbara Fasola, CEO of DialCare. “We are excited that teledentistry will now be available to everyone in the state which we so proudly call our home.”

DialCare president Jeremy Hedrick testified in support of the bill, attended stakeholder meetings, and met with legislators and staff. The company said that he also worked closely with Perry to work through contentious issues and to convey the importance of the bill up until its passage.

“DialCare truly appreciates the opportunity to be involved in the passing of the teledentistry bill into law,” said Hedrick. “Now, Texans will be able to connect with dentists by phone or video consultation for advice on their oral health concerns, conveniently and affordably.”

“Throughout the COVID-19 shutdowns, patient access to telehealth services became essential. The Legislature responded by adding dentistry to the Texas telehealth statute,” said Perry.

“Teledentistry better connects patients with their dentists by allowing them to offer services beyond the brick and mortar office. By passing this law, more underserved Texans will have better access to preventative dental care and be able to live a healthier life through the care they will receive,” Perry said.

“It was an honor to work closely with the legislators who shepherded this bill through the arduous process of becoming law,” said McWilliams. “I personally want to congratulate Senator Perry and Representative Klick on this tremendous accomplishment.”

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Despite mandatory state dental coverage, children in the foster care system face significant barriers to accessing oral healthcare, according to the University of Minnesota. For example, most children in the foster care system have medical and dental coverage through Medicaid, but few providers participate in Medicaid or in the Children’s Health Insurance Program.

Researchers at the school compared the self-identified oral health needs and access to dental care among youth who have and have not experienced foster care. Data was drawn from the 2019 Minnesota Student Survey, which polled public school students in the fifth, eighth, ninth, and eleventh grades.

Youth with a history of foster care were compared to youth with no history of foster care on seven oral health indicators. They also were asked whether or not they had experienced five types of dental problems in the past 12 months:

• Toothaches or pain
• Decayed teeth or cavities
• Swollen, painful, or bleeding gums
• Inability to eat certain foods because of a dental problem
• Missing one of more school days because of a dental problem

Youth who reported a dental problem then were asked if the issue was treated by a dentist and when they last had an appointment at a dental office for a checkup, exam, teeth cleaning, or other dental work. They also were asked about routine dental care, including checkups, exams, cleanings, or other dental work.

“To our knowledge, this study is the first in the United States to survey youth with a history of foster care about their oral healthcare needs using their own words,” said coauthor Elise W. Sarvas, DDS, MSD, MPH, associate professor in pediatric dentistry at the University of Minnesota School of Dentistry.

“We found that compared to their peers, youth with a history of foster care have self-identified dental needs, including issues with pain, and they have less access to a dentist to address these needs,” said Sarvas.

Specifically, the study also found that:

• Youth with a history of foster care were more likely to report each of the five dental problems and less likely to report receiving dental care, compared to their peers with no history of foster care.
• Approximately 44% of youth with a history of foster care reported at least one dental problem, compared to 32.2% of youth with no experience of foster care.
• Youth with a history of foster care had lower odds of seeing a dentist for a dental problem, 58.2% versus 71.2%, or for routine dental care, 69.6% versus 84.4%, than their peers with no history of foster care.

“There are likely a number of reasons why youth with a history of foster care have more dental problems relative to their peers,” said coauthor Rebecca J. Shlafer, PhD, MPH, assistant professor at the University of Minnesota Medical School.

“Compared to their peers, foster youth in this sample were more likely to report living in households experiencing poverty. Dentists should recognize the oral health concerns of this group of kids in the context of their special healthcare needs and be prepared to render appropriate care,” said Shlafer.

According to estimates from the US Department of Health and Human Services Children’s Bureau, there were 673,000 children in or entering foster care in the United States in 2019.

The Minnesota Department of Human Services reports that approximately 15,300 children experienced foster care in the state in 2019. Minnesotan children of color were overrepresented compared to the general population, with Native American children 18 times more likely and Black children three times more likely to experience foster care than White children.

The study, “Oral Health Needs Among Youth with a History of Foster Care: A Population-Based Study,” was published by JADA.

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As society gradually returns to normal, dental practices are hiring again too, according to the ADA Health Policy Institute (HPI). But they’re facing a lot of challenges, according to the organization’s May 17 poll of 1,712 dentists.

The ADA HPI reports that 28.8% of dental practices are looking for dental hygienists, 35.8% are recruiting dental assistants, 13.1% are hiring dentists, and 26.5% are searching for administrative staff.

However, 66.3% of those who are recruiting said that looking for dental hygienists has been extremely challenging compared to before the pandemic. Similarly, 59.2% said the same about dental assistants, 32.2% said dentists were extremely challenging to find, and 44.0% were extremely challenged in their administrative staff searches.

The salaries of many of these employees are going up too compared to pre-pandemic paychecks, with 70.7% of practices giving raises to their hygienists, 73.1% increasing pay for assistants, 34.1% boosting the bottom lines of dentists, and 67.1% of administrative staff seeing more money.

But these expenses have to be paid for somehow. According to the poll, 27% of respondents said their practices were enrolled Medicaid providers prior to the pandemic. However, 8% of practices have disenrolled from Medicaid since the pandemic’s onset.

Fortunately, patients are more interested in aesthetics. The ADA HPI said that 10.1% of practices are providing more orthodontic treatment; 9.3% are providing more in-office whitening treatment; 9.7% are providing more whitening via over-the-counter products; and 10.7% are providing more other types of cosmetic treatments.

The pandemic drove more patients do-it-yourself dentistry too, which brought them into the dental office. The poll said that 22% of respondents treated patients who attempted DIY procedures while COVID-19 raged on. Also, 44.4% of these patients were whitening with home remedies, 15.9% were trying tooth extractions, and 70.1% involved other issues.

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The Upper Allegheny Health System (UAHS) has resolved a former employee’s claims alleging that it billed Medicaid for dental services where it failed to sterilize dental handpieces between patients and treated patients with unsterilized and potentially dangerous tools.

As part of the agreement with the New York State Office of the Attorney General, UAHS will pay $2.7 million to the United States, New York, and Pennsylvania, with $2.4 million specifically resolving claims pertaining to New York’s Medicaid program.

“Patients visit medical offices to seek treatment, not further endanger their health by coming in contact with unsterilized tools,” said New York Attorney General Letitia James, who worked with the United States Attorney’s Office in the Western District of New York and Pennsylvania.

UAHS is a domestic not-for-profit corporation that operates several dental clinics in the Southern Tier of New York and Pennsylvania.

“It is shocking that the Upper Allegheny Health System skirted protocols and risked the safety of its patients, but what’s worse is that we may have never known about these disturbing practices had a whistleblower not come forward,” James said.

James added that the agreement “sends a message that real safety protocols must be followed to protect patients going forward. My office will always fight to hold accountable those who cut corners and risk patient safety.”

Between April 1, 2010, and May 31, 2015, UAHS allegedly conducted dental services with dental handpieces that had not been heat sterilized between patient use and subsequently billed Medicaid for these services.

Not only did the use of these unsterilized tools pose a health hazard to patients, the Office of the Attorney General said, but the billing of these services to Medicaid violated both New York state and federal laws.

The US Centers for Disease Control and Prevention, the ADA, and the manufacturer of the dental tools all require dental handpieces to be heat sterilized between patient use.

The investigation commenced after a former UAHS employee filed a whistleblower complaint under the qui tam provisions of the New York False Claims Act and the federal False Claims Act in the US District Court for the Western District of New York.

The New York False Claims Act allows individuals represented by counsel to file actions on behalf of the government and share in any recovery.

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The Minnesota Dental Association (MDA) is calling on state legislators to address oral health priorities in special session, as current dental provider reimbursement rates in the state’s Medicaid program are based off average submitted charges from 1989.

These 32-year-old rates are inadequate and, for many dentists, can mean the difference in program participation, the MDA said. Minnesotans need access to care, the MDA continued, and the state can’t wait another year to invest in a neglected system.

The outdated rates and lack of state investment have resulted in Minnesota having some of the lowest reimbursement rates in the country, the MDA said, with a detrimental impact for children and adults on Medicaid.

According to the Minnesota Department of Human Services, more than 60% of children on the state Medicaid program did not see a dentist in 2016 or 2017.

Through the 2021 legislative session, members of the state’s House and Senate Health and Human Services committees acknowledged the low reimbursement rates for dental providers and the impact it has had on access to care in Minnesota, the MDA said.

“I’d like to see more Medicaid patients in my community and provide them with the dental care they require, but the current system makes it difficult to meet those needs,” said MDA president-elect Dr. Amber Cziok.

“The problem is critical and during the time the state delays finding a real solution to this problem, patients continue to receive less care. Not addressing this immediately means we will be scrambling to mitigate the oral health needs of the unseen patients for years to come,” she said.

Many residents are seeking care in the emergency room instead of going to the dentist, the MDA said, which is expensive for the state and results in these patients not getting the dental care they need.

Legislators need to pass real solutions in this session that will improve access to care in Minnesota and ensure that state dollars are being used to provide appropriate care, the MDA said.

“We have heard from many of our members who see Medicaid patients. They have expressed that COVID-19 has put a further financial strain on their clinics, and they are having to make difficult decisions when it comes to Medicaid participation,” said MDA executive director Carmelo Cinqueonce.

“It’s time for Minnesota to properly address the woefully underfunded dental Medicaid program so patients can get the care they deserve and need,” Cinqueonce said.

Two proposals included in the House version of the Health and Human Services Omnibus bill will address the complexity of the system and the reimbursement rates, the MDA said. These proposals are desperately needed, the MDA continued, and could result in higher provider participation so more patients can be treated by a provider in their community.

The first proposal would update the state Medicaid rates and reset them from 1989 to 2018. The second would shift management of the dental program to a single entity for greater transparency and administrative simplification, the MDA said.

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Two dentists in North Texas, their dental management companies, and certain affiliated pediatric dental practices have paid $3.1 million to the United States to resolve allegations they defrauded the Texas Medicaid program and violated the False Claims Act by knowingly billing for pediatric dental services that were not rendered or that falsely identified the person providing the service.

“These defendants knowingly defrauded Medicaid, a program that provides medical coverage for more than 4 million low-income Texans,” said Acting US Attorney Prerak Shah of the Northern District of Texas. “If they thought they could get away with this scam by targeting underprivileged populations, they were sorely mistaken.”

Gunjan Dhir and Gaurav Puri have owned and operated dental clinics and dental management companies throughout Texas since 2009. The clinics serve primarily low-income children enrolled in the Texas Medicaid program. The dental management companies provide management and administrative services to the clinics. After opening their first clinic in 2009, Dhir and Puri expanded their operation to 35 clinics operating statewide by 2015.

The settlement resolves allegations that between May 30, 2011, and May 30, 2017, Dhir, Puri, and their affiliated management companies and pediatric dental clinics submitted or caused the submission of false claims for payment to the Texas Medicaid program for fillings in children that were not actually performed.

Also, the settlement resolves allegations that they submitted or caused the submission of claims using erroneous Medicaid provider numbers misrepresenting the dentists who performed pediatric procedures.

Funded jointly by the states and the federal government, Medicaid is intended to serve low-income families and children. The State of Texas paid for part of the Medicaid claims at issue and will receive approximately half of the government’s share of the settlement amount.

Part of the allegations resolved by this settlement were originally filed under the qui tam, or whistleblower, provisions of the False Claims Act by relators Sandy Puga, Nelda Torres-Brown, and Sonia Cardoso, all former employees of the implicated dental management companies and/or pediatric dental practices, who will receive a fraction of the settlement. The act permits private persons with evidence of fraud to sue on behalf of the government for false claims for government funds and to receive a share of any recovery.

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Most of the dental profession has been well aware of the ongoing exploitation of the dental Medicaid program for decades. This has included abuse and fraud with billing for restorative services never provided, unlawful upcoding, and billing without required records for treatment rendered.

Exploitation has also encompassed “patient churning” at nonprofit and public Federally Qualified Health Centers to increase “patient encounters” unlawfully and excessively, increasing remuneration.

Less may be known related to corruption in Medicaid orthodontics. Problems in this arena are no less disturbing.

Massachusetts

A recent wakeup call was the lawsuit filed by Massachusetts Attorney General Maura Healey against orthodontist Mouhab Z. Rizkallah, DDS, MSD, and his companies, which operate six clinics in the Metro-Boston area.

“For years, this orthodontist used his young patients as pawns to steal millions of dollars from the state,” said  Healey. “This illegal behavior harmed families from low-income communities and communities of color who rely on MassHealth for healthcare coverage. We are suing to hold Dr. Rizkallah accountable for these exploitative practices that victimized vulnerable residents in Massachusetts.”

Filed in Suffolk County Superior Court on February 25, 2021, the action alleges Rizkallah rendered and billed for medically unnecessary services. The complaint further alleges patient treatment times were unnecessarily extended to maximize payments from MassHealth, and not in the patients’ best interests.

Another allegation contends that over-the-counter athletic mouth protection guards were purchased at retail outlets for $9.99. Staff were allegedly instructed to remove packaging and the price stickers before distribution to patients. MassHealth was apparently billed between $85 to $95 for each guard, which ran up a total of over $1 million for the years in question.

Texas

Probably historically the most egregious Medicaid orthodontic fraud and abuses have occurred in Texas. Many authorities have alleged that between 2008 and 2010, Texas paid out more for Medicaid orthodontics than the other 49 states combined. Some contended that these claims overstate the actual figures. Regardless, billings under Texas orthodontic Medicaid were outrageous.

Many bad actors were on the stage. Some pointed their finger at Texas state authorities including former Texas Medicaid director Billy Millwee for alleged gross incompetence and/or corruption. Purportedly, government authorities were not watching the state’s cash register.

In fact, Texas’ state government oversight was so remiss that The US Health and Human Services Office of Inspector General recommended Texas refund $133,370,225 to the federal government, determine and refund the federal share of any additional amounts related to orthodontic prior authorizations that the state agency improperly claimed after its audit period, and monitor the orthodontic program to ensure it complied with Texas Medicaid guidelines.

Another avenue for failure came from alleged rubber-stamping of billing claims by Xerox, which the state retained to be its managed care organization (MCO), and its subordinate company, Conduent.

Texas Attorney General Ken Paxton claimed Xerox failed in its mandated oversight review of Medicaid orthodontics between January 2004 and March 2012. Allegedly, many thousands of children were treated for orthodontics who either did not require treatment or only had cosmetic issues that did not meet the required standard of medical necessity. The settlement amounted to $235.9 million with no admission of wrongdoing.

Orthodontic providers also came into question. Lawsuits were filed. Some facilities subsequently closed their doors. Others continued on after paying out settlements. One of the more high-profile cases involved court adjudicated civil violations by Dr. Richard Malouf.

Also known for private jets, antique autos, and a waterpark at his former Dallas mansion, Malouf was held responsible by the 126^th District Court of Travis County for 1,842 unlawful acts under the Texas Medicaid Fraud Prevention Act and liable for approximately $16.5 million to the State of Texas.

Scope of the Problem

The orthodontic community, as well as the dental profession overall, is not experiencing problems with direct-to-patient services or orthodontic services covered by insurance plans, like one witnesses under various state dental Medicaid programs. One must rationally ask why the Medicaid program draws such difficulties.

Chirs Roberts, DDS, MS, president of the American Association of Orthodontists and an adjunct faculty professor at the University of Michigan, noted that Medicaid coverage and eligibility vary from state program to state program. Orthodontics coverage often is limited to children with craniofacial anomalies, for example, or to those who can present evidence that such services are medically necessary.

“In addition to the eligibility issue, documenting ‘medical necessity’ for Medicaid administrators is often labor-intensive for providers and their staff versus submitting claims to private insurance. Also, there is not a universally agreed upon definition of ‘medically necessary,’” said Roberts.

“The public benefits of including orthodontic care within the state Medicaid program are the same benefits as with private paying orthodontic patients. These benefits include both improvements in dental function and dental aesthetics,” said Christine Porter Ellis, DDS, MSD, an orthodontist in private practice in Dallas who also has provided expert testimony and advisory service to legal offices, state agencies, and the US Congress.

“Improved dental function will result in a number of lifelong benefits, including better dental hygiene and periodontal health, with the ultimate goal of improved overall health throughout life,” Ellis said.

“Improving dental aesthetics is also beneficial in both the short and long term. Children with favorable dental aesthetics are at less risk for bullying and social exclusion. Adults with favorable dental aesthetics are more likely to obtain jobs with better pay. For patients, both public and private, there is truly little downside to receiving high quality orthodontic care,” Ellis said.  

“There are a number of problems with the way that orthodontic care is managed by many state Medicaid programs. Upcoding, billing for appliances and services that were not delivered, delivery of appliances and services that are not necessary (overtreatment), and kickback schemes are all ways that Medicaid dollars can be fairly easily looted by unscrupulous billers. The problems that were exposed in Texas nearly a decade ago still remain as evidenced by the recent Massachusetts AG actions against Dr. Mouhab Rizkallah,” Ellis said.

“Given that both state and federal legislatures have been made well aware of these problems for many years, I have concluded that the biggest problem with the way that Medicaid orthodontics is managed is the total failure by many state legislatures to ensure the integrity of the orthodontic Medicaid program. Fraud can easily be stopped when there is political will to stop it. States have the resources and tools to competently manage Medicaid. Some do, but many don’t,” Ellis said.

What Is the Solution?

Roberts advised improving Medicaid coverage from both an eligibility and financial standpoint.

“This starts by recognizing that patients with craniofacial anomalies or other medical necessities are not the only individuals for whom orthodontic care would be medically beneficial. Having a healthy bite is an important part of a person’s overall health,” Roberts said.

“Lastly, Medicaid is an extraordinarily complex topic that varies from state to state. Due to these obstacles, the AAO Foundation created the DOS (Donated Orthodontic Services) program to provide financial assistance for children,” Roberts said.

Ellis suggested examination of the link of risk to reward.

“The entities that enjoy the most reward from participating in the orthodontic Medicaid program are those pocketing the most Medicaid dollars. These entities are both the MCOs and the big DSO Medicaid dental office owners. None of these entities hold any real risk for fraudulent billing or poor patient care. All of the risk lies with the individual providers through licensure and liability claims,” Ellis said. 

“To protect Medicaid orthodontic patients from harm and public dollars from fraud, state legislatures must focus Medicaid enforcement against those who pose the biggest threat and who are collectively the biggest stakeholders to policy change. MCOs and large DSO organizations must face significant risk along with the individual providers,” Ellis said.

“To improve the orthodontic Medicaid program, state legislatures must pass Medicaid Integrity measures that place significant risk of legal action and state enforcement squarely on those entities which are receiving the largest amount of money from the Medicaid program, namely the MCOs and the large DSO dental office owners,” concluded Ellis.

Conclusion

Both Roberts and Ellis offer an outstanding overview of the problematic landscape of our dental Medicaid orthodontic program. Both suggest viable solutions.

Charitable activities like the one espoused by Roberts can assist many in need. Though valuable, however, sole reliance upon charity for Medicaid orthodontic answers can only serve as a limited stopgap measure. 

The question remains if taxpayers, through their elected representatives, have the motivation and willpower to carry through with necessary reforms and enforcement. Or will governmental authorities continue to be largely influenced by the larger stakeholders of interstate MCOs and larger corporate DSOs?

Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Santa Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at mwdavisdds@comcast.net or smilesofsantafe.com.

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The Oklahoma Health Care Authority (OHCA) has awarded a one-year dental benefit management contract to DentaQuest, the nation’s largest and most experienced Medicaid dental benefits administrator, according to the company.

OHCA selected DentaQuest, LIBERTY Dental, and MCNA Dental to administer benefits for the more than 770,000 Medicaid-enrolled eligible adults and children statewide.

“We are honored to support the state by ensuring access to high-quality oral healthcare for SoonerCare members,” said Dr. Jandra Korb, dental director for DentaQuest Oklahoma.

“DentaQuest is also proud to support Governor Stitt’s plan to transform Oklahoma into a top 10 state in terms of health outcomes, including oral health,” Korb said.

“We will do this by implementing time-tested and cutting-edge approaches to improve oral health outcomes, increase care access, and improve accountability across our system,” Korb said.

In alignment with the state’s goals, DentaQuest said it is specifically focused on ensuring more people see a dentist at least once a year with programs that establish dental homes for children and adults, support patients who previously have missed dental appointments, and enable much needed care for those who have been historically marginalized.

DentaQuest said it will lead a combination of high-touch interventions including case management, targeted enrollee education and incentives, and grassroots community-based outreach.

The boots on the ground approach will help counter some of the unique barriers to care faced by Medicaid populations across Oklahoma’s urban and rural geographies, including the state’s 38 tribes and tribal organizations and its growing Hispanic/Latinx population, DentaQuest said.

DentaQuest also will be expanding benefits for pregnant women over the age of 21 by covering dental cleanings. Previously, pregnant women only were eligible for extractions, despite being at high risk for early stage periodontal disease according to the Centers for Disease Control and Prevention.

Since last year, DentaQuest said, it has held meetings with stakeholders across Oklahoma to learn about unique populations, regional variation, program strengths, opportunities for improvement, and barriers to care.

DentaQuest also said it has met with organizations representing a range of populations and perspectives including tribal officials, Indian Health Services, community organizations, safety net providers, public health agencies, foundations, and dental schools.

The feedback and input these meetings will inform DentaQuest’s innovative approach to oral called Preventistry, which emphasizes education, accessibility, early intervention, and prevention, the company said, helping to deliver the governor’s plan to improve health outcomes for all state residents.

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