In April, 2014, 300 dentists throughout Nebraska, many specializing in children, received a letter from a contractor for Medicaid. The letter warned they would be subjected to a RAC audit.
I was among those dentists.
RAC stands for the Recovery Audit Contractor program, which started with Medicare, then was extended to Medicaid under the Affordable Care Act. It enables private contractors to demand patient records, conduct audits on providers, and collect a percentage of any refunds.In Nebraska, the audit aimed to scrutinize how frequently we performed cleanings for Medicaid patients. For every patient seen more frequently than every six months, we would have to refund a $22 reimbursement for “excessive” teeth cleaning.
So began an ordeal for the one-third of all dentists in Nebraska who care for low-income Medicaid patients. The episode is a cautionary tale about government overreach.
A recent report from the U.S. Department of Health and Human Services injects fresh urgency into the issue, finding 75 percent of children on Medicaid in four states – California, Indiana Louisiana and Maryland – are not getting required dental care. The report calls for the Centers for Medicare Medicaid to work with states to identify barriers preventing providers from participating in Medicaid.
As it happens, provider manuals in Nebraska give dentists discretion to determine frequency of treatment. This freedom is valuable. Low-income patients, particularly children, are more high-risk, and may need care more often than every six months. Children in Medicaid typically face dental issues more dire than those privately insured. A toothache can easily graduate into dental disease, causing pain, absenteeism from school, and even inability to eat.
Checkups conducted more often than every six months can thus be preventive, rendering emergency treatments unnecessary and translating into improved dental health and money saved. In fact, the American Academy of Pediatric Dentistry recommends “more frequent cleaning if the child is at moderate or high risk for dental disease.”
Nebraska is more sparsely populated than most states, with some rural counties having only one dentist. Low-income families may have to drive hours to see a dentist who takes Medicaid.
Our auditors apparently understood little or none of this. Dentists audited had three basic options. Pay the fines, with no questions asked, even if certain we had followed the rules. Pay the fine and drop out of Medicaid. Or hunker down in a cubicle to comb through every patient chart and appeal the claims.
Most dentists in Nebraska, as elsewhere, are solo practitioners, ill-equipped to face such an accounting challenge on short notice. Contesting a claim might mean closing shop for a day or more, losing the opportunity to see patients who needed to be seen.
Many of our dentists simply wrote a check, even if believing the audit to be unfair, because the average refund might cost less than poring over paperwork. One pediatric dentist, dinged for 2,200 cleanings, had to fork over $48,000. Other dentists either cut back drastically on caring for Medicaid beneficiaries, stopped seeing those patients altogether, or referred patients to colleagues still in the program. One of Nebraska’s largest dental practices, with 20 clinics primarily serving rural areas, has stopped seeing Medicaid patients.
Three-quarters of the cases ended up dismissed and called into question whether the audits were necessary in the first place.
All this adds up to bad medicine and bad business. These auditors questioned our practices as dentists without any background in health care or dentistry, let alone the needs of the children we treat. They merely ran algorithms, looked at our numbers, looked for loopholes to exploit, and then accused us of overbilling for our services.
Clearly, the flawed model of the RAC audit is a barrier. Unearned payments should be stopped before the fact rather than after.
RAC audits are happening nationwide not only to dentists but also to physicians, hospitals and other healthcare providers. The audits recouped $57.7 million in improper payments in 2015. But recently, complaints that the administrative burdens interfere with patient care have prompted CMS to scale back such audits on hospitals. Now CMS is searching for new contractors. But physicians – and dentists – remain unprotected.
The highest price here is paid by our patients, including disadvantaged children of all ages. Losing access to care takes a toll on entire communities.
Even though our new state Medicaid director appears to be moving in a promising direction, at least three other states have undergone such audits. My colleagues and I may have served only as canaries in the mine.
Jessica Meeske, DDS, is on the Council of Government Affairs for the American Academy of Pediatric Dentistry.