LINCOLN — National and state dental leaders are raising the alarm over Medicaid audits that they say threaten the care of young children in Nebraska with mouths full of rotting teeth.
The audits led one pediatric dentist in Lincoln to stop seeing Medicaid patients, a step that left the Lincoln-Lancaster County Health Department’s dental program without anyone to treat the most severe cases.
He quit this fall after paying $50,000 to the government in a settlement agreement and another $75,000 in legal fees.
Three other pediatric dentists face the prospect of having to repay as much as $200,000 for questioned procedures.
“The end result is that the audit has harmed children’s access to oral health care while recovering a pittance of overall Medicaid spending in the state,” the dental leaders wrote in a letter to Nebraska’s top Medicaid official.
The Nov. 6 letter was signed by the presidents of the American Dental Association, American Academy of Pediatric Dentistry, Nebraska Dental Association and Nebraska Society of Pediatric Dentistry. It called for the Nebraska Department of Health and Human Services to halt current Medicaid audits and make changes in any future ones.
Dr. Jessica Meeske, a pediatric dentist in Hastings, said Thursday that the dental leaders have not received an answer to their letter.
HHS officials issued a statement when The World-Herald asked about concerns raised in the letter. The statement says that the audits are required by federal law and that the federal Centers for Medicare & Medicaid Services has contracted with a private firm, AdvanceMed, to do them.
“We understand and appreciate it takes time for providers to respond to an audit,” the statement said. “The purpose of an audit is to ensure that taxpayers dollars are being spent appropriately.”
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Meeske said the biggest issue in the audits has been whether to use crowns or fillings for children with severe early childhood cavities.
These are children whose average age is 4 and who have cavities in more than half of their 20 baby teeth. Because of their age and the extent of their dental disease, they have to be treated under anesthesia in a hospital operating room.
“These aren’t kids with little holes in their teeth; these are kids that are really sick,” Meeske said.
Pediatric dental guidelines call for using stainless steel or white plastic crowns in such cases. The crowns last longer than fillings, which means that the children are less likely to need anesthesia again. Those are the guidelines that the audited dentists followed.
But NCI AdvanceMed, the company contracted to do the audit, said fillings should have been used as the “least costly restoration” in many of those cases. The company audited a sample of 40 of the Lincoln dentist’s cases, including one in which it approved of the first 17 crowns he used to fix a 3-year-old’s teeth but said he should have used a filling on the 18th tooth.
The auditors then calculated an overpayment total by extrapolating findings from the sample to 568 of his patients. They concluded that he should repay the difference between crowns and fillings for that group, or about $88,000.
Meeske, who looked at the Lincoln dentist’s cases, supported his choice of treatment. So did the dental leaders.
“This dentist considered the least costly option in the context of the life of the tooth, the risk factors for future disease and the life of the child,” the letter said.
The leaders said the audit was flawed because it did not follow the treatment guidelines for the profession. In addition, the reviews were not conducted by pediatric dentists. Initial reviews were performed by a general dentist who does not treat many Medicaid patients, Meeske said. Reviews on the first round of appeals were conducted by a registered nurse.
The result put the audited dentists in a professional bind, she said. If they followed their professional training and practices, they would be at odds with Medicaid. If they treated children as the auditors required, they could be in trouble with their licensing board.
An AdvanceMed spokeswoman referred questions about the audit to CMS, the federal Medicaid agency. A CMS spokeswoman pointed the finger at Nebraska Medicaid.
The CMS spokeswoman said auditors follow dental policies established by state Medicaid agencies, rather than professional guidelines, in determining whether a particular treatment is appropriate and qualifies for Medicaid reimbursement. She also said state Medicaid agencies set the qualifications for reviewers used by the auditors.
“The auditors followed Nebraska Medicaid dental policies as well as Nebraska audit procedures,” she said.
The HHS statement did not specifically address questions about why the department allowed audits that called for dentists to contradict professional guidelines or about whether officials are concerned about the effects of the audits on access to care.
“Just like insurance, Medicaid covers certain services under certain circumstances and does not direct treatment decisions,” the statement said. “This particular audit is required by federal law and is being performed by a company hired by the federal government. Specifically, federal law provides for auditing of claims to identify whether fraud, waste or abuse has occurred or is likely to occur.”
The issue has drawn the attention of state lawmakers. The Legislature’s Health and Human Services Committee plans a briefing on the subject Friday morning.
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