Assumptions

The American Dental Association's Medicaid dental initiative should hasten the evolution of this federal/state partnership toward a more accountable program that demonstrably improves the oral health of Medicaid eligible citizens. Success of the ADA's initiative can lead to a Medicaid dental program that will:

• Emphasize outcome measures that reflect improvement in the oral health of eligible Medicaid recipients.
• Require actuarially sound and market-based reimbursements to dentists and health care facilities.
• Allow community-based care delivery innovation.
• Promote the development of symbiotic collaborations in the community to improve access and effectiveness of oral health care delivery.
• Maintain state level dentist peer review oversight to assure appropriate, cost effective Medicaid oral health care delivery.
• Promote state financial risk retention as well as eligibility determination and provide incentives to expand dental coverage for under served populations.
• Require state program management and cost control through partnerships with organized dentistry, dental plans and consumer representatives.

The Role of Dental Plans

Dental plans should play a central administrative role in the future state of the Medicaid dental program. Dental plan core competencies are claim management, utilization management, cost control, network development and maintenance, and outcome reporting. Dental plan personnel also have experience in quality assurance and oral health care delivery models.

Dental Medicaid Program Administration

With market-based dentist reimbursements, Medicaid eligible recipients can be provided coverage that is no different form commercial dental plan products. Rather than create a separate Medicaid dental program, existing dental plan products can be modified to comply with EPSDT or other state and federal requirements. In addition to being a more efficient administrative process, Medicaid recipient will no longer be stigmatized by having present a Medicaid identification card when seeking dental care. A core function of dental plans, is the management of reimbursement arrangements using sophisticated claim processing platforms. Coupled with trained and motivated customer service representatives, existing claim processing efficiencies and dentist acceptance can be integrated into the Medicaid dental program.

Medicaid financial risk retention by states will remove the dental plan disincentive related to improving access to care. Dental plans should contract with states through administrative service agreements while states collaborate with dentists and financial consultants to develop Medicaid resource allocation and control procedures compatible with the availability of public funds and state legislative agendas.

Network Development

Dental plans have heavily invested in the development and maintenance of dental networks and have established standards to assure assess to general dentists and specialists. The creation of an adequate Medicaid dental network has been a failure in most of the United States. The use of existing networks will not only reduce Medicaid costs but also better assure adequate assess.

Program Innovation

Community based collaborations

Dental plans often include community service as part of strategic business development. These initiatives may include collaboration with health care and social service agencies that have missions related to oral health care delivery. Many community-based collaborative models with documented positive outcomes are available for study and replication.

Care delivery models

Dental plans operate staff model oral health care delivery systems where there is inadequate dental manpower in the private practice sector or where there are positive strategic business relationships with other health care entities such as hospitals. Many of these models have long term financial and clinical success and could be suitable for Medicaid care delivery replication.

Outcome Reporting

Most dental plans use claim-processing systems that allow data formatting or downloading for a variety of outcome reports. Outcome measures need not be costly direct patient oral assessment. Indirect, NCQA-like indicators such as preventive procedure frequencies, self-care knowledge assessments and mix of restorative procedures can be used to indicate program effectiveness. Greater accountability of the dental Medicaid program can be attained through the use of dental claim history data:

• Utilization reports that demonstrate frequency and cost by dental treatment codes

• Retrospective studies to determine the appropriateness of rendered dental care

• Retrospective reviews must include peer review panels of dentists who can render opinions on practice patterns and care appropriateness

• Comparative studies using claim history and epidemiological data such as caries assessment studies

Quality Assurance

Credentialing of dentists most often includes these components:

• Primary source accredited dental school graduation and state licensure certification

• Disclosure of past or pending malpractice litigation, license restrictions or health care facility sanctions

• Office inspections to assure OSHA compliance, adequate record keeping and patient access standards compliance

In addition to credentialing, dental plans also maintain a patient complaint resolution service, pre-payment review procedures, denied claims appeal systems and utilization management programs.

Communication

Dental plans have regular patient and doctor communication vehicles for administrative and clinical information. Newsletters, check stuffers and single-issue announcements are commonly used. Many health care plans are investing in health promotion education on Web sites and in written media. All of these sources are available for Medicaid program communication.

Gary A. Colangelo, DDS
Gary.colangelo@carefirst.com
410 528 7908