Transcript MEDICAID DENTAL PROGRAM Policy Review

MEDICAID DENTAL PROGRAM
Policy Review
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Wyoming Medicaid is a joint federal and state
government program that pays for medical and
dental care for low income and medically needy
individuals and families.
Wyoming Medicaid benefit expenditures generally
receive 50 percent Federal match (FMAP).
Medicaid provides medical assistance for lowincome and medically vulnerable citizens. There
are currently four major categories of eligibility:
Children, Pregnant Women, Family Care Adults,
and Aged, Blind or Disabled (ABD).
What is Medicaid?
The Patient Protection and Affordable
Care Act (PPACA), commonly called the
Affordable Care Act (ACA) or "Obama
Care", is a United States federal statute
signed into law by President Barack
Obama on March 23, 2010.
 Under the law, a new “Patient’s Bill of
Rights” gives the American people the
stability and flexibility they need to make
informed choices about their health.
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What is the Affordable Care Act
(ACA)?
Expands income eligibility for children
 Transitions children from Kid Care CHIP to
Medicaid
 Implements the Modified Adjusted Gross
Income (MAGI) eligibility for children,
pregnant women and family care adults
 Expands the availability of Medicaid
benefits to former foster care children
until age 26
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How does the ACA impact
Wyoming Medicaid?
Children’s program is mandatory by the
federal government and covers all
services needed to prevent and treat
dental diseases and restore function.
 Adult program is optional and can be
limited to basic services as determined by
each state.
 Expansion of the adult coverage range is
optional and must be passed by the
legislature and governor for each state.
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Medicaid Dental
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The Division of Healthcare Financing
administers the Medicaid program. They
are responsible for financial management,
developing policy, establishing benefit
limitations, payment methodologies, and
fees, and performing utilization reviews.
State Duties vs. Fiscal Agent
Duties
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The Fiscal Agent (Xerox Healthcare
Solutions) processes all claims and
adjustments. They also answer provider
inquiries regarding claims status,
payments, client eligibility, known third
party payers and provide onsite visits to
train and assist your office staff on
Medicaid billing procedures or to resolve
claims payment issues.
State Duties vs. Fiscal Agent
Duties
The Medicaid Dental Manager is
responsible for presenting new policies,
codes, and fees to the Medicaid Dental
Advisory Group (DAG) for consideration.
 The DAG is made up of 6 dentists and
Department of Health and Fiscal Agent
employees.
 The DAG collectively reviews new or
changes to existing policies for
compliance with industry standards.
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Who reviews dental policies?
 When would the DAG review a policy?
1.
New ADA codes
2.
Provider requested fee increase
3.
Data shows outliers in billed charges
4.
Clinical appeals from providers
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The DAG members also provide
professional advice and expertise on
current acceptable dental practices.
What does the DAG do?
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Dr.
Dr.
Dr.
Dr.
Dr.
Dr.
Jay Cole- Pediatric Dentist-Cheyenne
Jim Nelson- General Dentist- Worland
A. Bryce Castillon- General Dentist- Green River
Thomas Zumo- General Dentist- Cheyenne
Matthew Henry- Pediatric Dentist- Cheyenne
Jim Hoag- State Orthodontic Consultant
Members from the Wyoming Dental Association are invited to
attend and participate at quarterly meetings as
representatives of the professional association in Wyoming.
Who are the current DAG
members?
The Oral Health section of Public Health is
not funded or managed by Medicaid.
 Public Oral Health has many programs
that are paid for by State general funds to
help assist uninsured or underinsured
dental patients.
 These programs include: Senior Dental,
Marginal Dental, Sealant Program, Cleft
Palate Program, and part of the Severe
Malocclusion Program.
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What is Public Health Dental?
Public Oral Health has a manager,
Cassandra Walkama RDH, MPH and a
dentist, Dr. Edward Lawler.
 These programs were previously
administered by Trish O’Grady and Peggy
Baluska.
 Public Oral Health also employees 4
Community Oral Health Coordinators
(public health hygienists).
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Who is in charge of Public Oral
Health?
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In 2015, 231 of the 295 licensed,
practicing dentists in Wyoming are
enrolled as Medicaid providers
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WY ranks in the top 10 for provider
participation and fee reimbursement in
the nation. 78% of licensed dentists are
MC providers. The national average is
(40-50%)
How many dentists participate
with WY Medicaid?
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As of March 2015 there were:
46,456 children on MC
27,288 adults on MC
2,106 nursing home residents on MC
**Of the 46,456 children on MC in 2015,
only 21,838 (47%) have been seen for a
dental visit and only 18,701 (33%) have
had a prophy
How many Medicaid clients are
there?
Bill claims timely, within 12 months to avoid
timely filing denials
 Retain adequate records
 Inform clients, in writing, if a service is not
covered or if the client has used their benefit
limits
 Report suspected abuse or fraud by another
provider or eligible client (page 4-5)
 Check client eligibility prior to rendering services
 Review and understand all policies contained in
the provider manual
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What are my requirements as a
provider?
Medicaid Program Integrity Unit is in place
to do the following:
1. Review of claims submitted for payment
2. Review of dental records related to
covered services
3. On-site review of dental records and
client interviews
4. Case management oversight
5. Recovery of overpayments or payments
made in error based on policies
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What is Program Integrity?
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Each employee in the provider office are
informed of Medicaid rules and policies
Records are kept accurately on each client
Access to client records as requested
Access to financial records of
reimbursement from Medicaid
Office policies are enforced the same for
all types of patients EX. Medicaid, Cash
pay, Traditional insurance
What is expected from Program
Integrity?
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A patient’s dental records must contain the
following information and be typed or legibly
hand written:
*Name on each page of the record
*Diagnosis of disease/conditions and history
*Treatment Plan
*All services rendered with:
>Tooth Numbers
>Surfaces
>Quantities
>Medications and dosages
>Observed conditions & progress at each visit
>Total treatment minutes if codes are used that are
reimbursed at 15 minute increments
What is required in the records?
The SMP is the orthodontic program for
Medicaid
 Clients can be referred to an orthodontist
if there malocclusion appear to meet the
set guidelines
 Clients go through an approval process
before ortho can be started
 Only clients who have poor malocclusions
that affect function EX. Speaking,
Chewing, Breathing, will be approved
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Severe Malocclusion Program