MEDICAID DENTAL PROGRAM Policy Review

Transcription

1 MEDICAID DENTAL PROGRAM Policy Review

2 What is Medicaid? Wyoming Medicaid is a joint federal and state government program that pays for medical and dental care for eligible low income and medically needy individuals and families. Wyoming Medicaid benefit expenditures generally receive 50 percent Federal match (FMAP). Medicaid provides medical assistance for low-income and medically vulnerable citizens. There are currently four major categories of eligibility: Children, Pregnant Women, Family Care Adults, and Aged, Blind or Disabled (ABD).

3 Medicaid Dental Children s program is mandatory by the federal government and covers all services needed to prevent and treat 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.

4 State Duties vs. Fiscal Agent Duties The Division of Healthcare Financing, Department of Health, administers the Medicaid program. They are responsible for financial management, developing policy, establishing benefit limitations, payment methodologies, and fees, and performing utilization reviews. Medicaid Dental Manager- April Wickham

5 State Duties vs. Fiscal Agent Duties The Fiscal Agent (Conduent) 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. Conduent Dental Supervisor/Field Rep- Amy Reyes

6 Who reviews dental policies? 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 and makes recommendations to the Medicaid Agent.

7 When would the DAG review a policy? New ADA codes Provider requested fee increase Data shows outliers in billed charges Clinical appeals from providers The DAG members also provide professional advice and expertise on current acceptable dental practices.

8 What are my requirements as a provider? Bill claims timely, within 12 months to avoid timely filing denials Retain adequate records to support billing 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 (section 4.9.1) Check client eligibility prior to rendering services Review and understand all policies contained in the provider manual

9 Dental Manual Updates All providers are responsible for using the most updated version of the Medicaid Dental Manual The manual is available on the Web Portal and can be searched using the Ctrl F option The manual is updated quarterly, online * January 1 st * April 1 st * July 1 st * October 1 st

10 What is Program Integrity? 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

11 What is expected from Program Integrity? 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

12 What is required in the records? 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

13 Referral of Suspected Fraud/Abuse Fraud Abuse An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare

14 Referral of Suspected Fraud/Abuse Provider should notify the Program Integrity Unit in writing if fraud or abuse is suspected Use referral form from manual (4.9.1) Call Provider is responsible for ensuring all employees are informed of rules and regulations pertaining to Medicaid

15 Client Eligibility Determined through Customer Service Center (CSC) Not determined through Conduent Different benefit plans- some cover dental and some do not Adults are issued eligibility month to month/children for a year If a client is not eligible, it is THEIR responsibility to call the CSC to update their coverage. Once a client has renewed it can take a few weeks to get the renewal approved and the system updated. Any claims that come into Conduent will be denied and not payable if the client was not updated in the system yet.

16 Provider Responsibilities- Accepting Clients Accept client as a Medicaid client upon 1 st visit if the provider is aware of the client s Medicaid coverage Check eligibility prior to rendering services Provider may decide not to further treat the client as a Medicaid client. If this occurs, provider must advise the client of this fact in writing before rendering treatment

17 Provider Responsibilities-Clients Without Medicaid Cards Provider may require the client to reschedule until a card can be presented Provider may see the client, verifying eligibility by using name, dob and/or social security number Provider may require the client to pay in advance for services. If the client produces a card at a later date and the provider agrees to accept the client as a Medicaid client, the provider must refund the entire amount paid by the client prior to billing Medicaid If a client fails to notify a provider of Medicaid eligibility and is billed as a private-pay patient, the client is responsible for the bill unless the provider agrees to submit a claim to Medicaid.

18 Provider Responsibilities-Medical Necessity Medicaid will pay only for medical/dental services that are medically necessary Medically necessary means the service is required to: Diagnose Treat Cure Prevent an illness

19 Provider Responsibilities-Medical Necessity Additionally, the service must be: Consistent with the diagnosis and treatment of the patient s condition In accordance with standards of good medical/dental practice Required to meet the dental needs of the patient and not the convenience of the patient or doctor Performed in the least costly setting required by the patient s condition

20 Billing of Deliverables Federal guidelines state that a service cannot be billed to Medicaid until it is completed. When billing for a deliverable (crowns, bridges, retainers, dentures) the provider must bill these procedures on the date of delivery. If these codes have been billed on the prep date, the provider is responsible for voiding their claim and re-billing it on the seat date prior to the 12 month timely filing deadline.

21 ORDER VS DELIVERY DATE EXCEPTION FORM (effective 6/1/17) Wyoming Medicaid will allow a provider to bill using the prep date of an item, only if one of the following conditions are present: 1. Client is not eligible on the delivery date but were eligible on the prep date 2. Client does not return to the office for pick-up of item after several documented attempts to contact the client.

22 ORDER VS DELIVERY DATE EXCEPTION FORM (effective 6/1/17) cont. A provider may use the prep date as the date of service only if they have obtained a sign exception form from the State. Below is the required process: 1. Print the Order vs Delivery Date Exception From from 2. Complete the form and fax or mail the form to the address at the bottom of the form 3. Once the form is signed by the State, it will be returned to the provider and must be a part of the client s permanent, clinical, record. 4. The provider may then bill the claim using the prep date as the date of service. NOTE: If an audit of clinical records is performed, and it is found that the provider billed on the order date but does not have a signed Order vs Delivery Date Exception Form for the client and DOS, the money paid will be recovered.

23 ORDER VS DELIVERY DATE EXCEPTION FORM

24 Limitations Fillings- 1/18 months per tooth Sealants- 1/18 months per tooth and not on the same day as a filling; ages 0-20 Crowns- only ages Implant/Bridge- 1/lifetime and only with a Prior Authorization (PA #) Dentures/Partials- 1/lifetime-adults, as needed for children NOTE: It is the provider s responsibility to check these limitations PRIOR to rendering these services. If your claim denies due to the benefit already being used, YOU MAY NOT BILL THE CLIENT unless you informed them, in writing, of the charges they may incur.

25 Limitations If the client is in need of a procedure, and the limitation has been used, the client has 3 options: 1. Return to the provider who did the procedure for repair/replacement at no charge to the client or Medicaid 2. Wait until the time limitation is up to have the procedure done 3. Agree to pay for the procedure- this should be in writing prior to rendering the service

26 Severe Malocclusion Program 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

27 EHR Incentive payments The Medicaid Electronic Health Care Record (EHR) Incentive Program provides incentive payments to eligible professionals as they adopt, implement, upgrade or demonstrate meaningful use of certified EHR technology Provider must see a 30% volume of Medicaid patients within their office and be using a certified EHR system Year one- $21,250 per doctor Year 2-6- $8,500 per doctor Contact- Ruth Friess

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