Medicaid RAC Audits Pose Threat to Children’s Access to Oral Health Care

Under the Affordable Care Act (ACA), the Medicare Recovery Audit Contractor (RAC) program was extended to Medicaid.  The RAC program allows private contractors to demand patient records and conduct audits on providers while retaining a percentage of any refunds collected.  
The AAPD and the American Dental Association (ADA) support efforts to detect, prevent, and eliminate any fraud and abuse from Medicaid dental programs.  However, the RAC program as currently operated is seriously flawed. In some states, this has resulted in unfair and unreasonable provider audits, penalizing pediatric and general dentists who are long-time Medicaid providers.  This has the potential to drive good providers out of the program, while discouraging new dentists from becoming Medicaid providers. Critical to Medicaid improving access to oral health care is keeping existing dentists while attracting new dentists into Medicaid participation. 
It is important for dentists to be evaluated by their peers, meaning that a dental specialist under review should be able to expect a similar specialist to conduct or consult on the audit.  Auditors should rely on policies and guidelines consistent with clinical guidelines of the AAPD and ADA. AAPD and ADA also recommend:
Simplifying Medicaid administration, especially with credentialing.
Providing dentists with data on utilization patterns in an early and timely manner.
Educating dentists on appropriate utilization patterns for a given patient risk profile.
Implementing consistent and statistically sound audit processes across communities and states. 
Developing a "Program Integrity Protocol Manual" for practitioners.
Two recent developments of note are:
Congressman Gosar Sends Letter to HHS Secretary Signed by 73 Other House Members
In June 2014 Congressman (and dentist) Paul Gosar (R-4th Ariz.) and a bi-partisan group of 73 Members of the House of Representatives sent a letter to the HHS Secretary requesting specific federal agency action to insure fair and reasonable RAC audits. Click here for a copy of that letter.
Nebraska Medicaid RAC Audit Issues Gain Congressional Attention
Pediatric dentist Dr. Jessica Meeske (Hastings, Neb.), presented testimony in July before a roundtable discussion hosted by the Senate Special Committee on Aging.  Committee members heard about the problems associated with the Medicare and Medicaid RAC programs. Below is coverage of that testimony from the online publication Dr. Bicuspid
Neb. dentists get audited for Medicaid prophies
By DrBicuspid Staff
July 17, 2014 -- Many Nebraska dentists have opted not to take any more Medicaid patients after being audited for $22 prophies, a pediatric dentist told a recent U.S. Senate hearing on Medicare and Medicaid.
Hundreds of Nebraska dentists recently were sent letters from the state's Medicaid recovery audit contractor (RAC), Health Management Systems (HMS), asking for charts containing adult and pediatric billing codes for prophylaxis, according to an ADA News story.
During her testimony at a July 9 Capitol Hill hearing, Nebraska pediatric dentist Jessica Meeske, DDS, who chairs the Nebraska Dental Association's Medicaid Committee, said the Medicaid RAC audit process lacks transparency and opportunity for feedback, and she offered recommendations to improve the process.
The hearing focused on Medicare audits and acknowledged growing concerns about Medicaid RAC audits, which began in some states in 2012.
Dr. Meeske described her experience with an RAC audit. She said one billing code involved a $22 cleaning fee, and noted that dentists could be audited if they billed the state for prophies that were done one day short of a patient's six-month visit.
RACs were created to find and recover overpayments and underpayments in the Medicare program, which were expanded to the Medicaid program by the Patient Protection and Affordable Care Act. Dr. Meeske said that neither she nor any dentists she knew had received compliance training, and there was no collaboration with the dental community on the audit process.
Nebraska's provider manual language was revised a decade ago to give dentists flexibility in the six-month prophy frequency, depending on the patient's risk for caries. Current language recommends a six-month frequency but also notes that the "frequency [will be] determined by the dentist," Dr. Meeske said. This corresponds with the American Academy of Pediatric Dentistry's dental schedule for children and allows high-risk children more frequent visits, when appropriate, to prevent more serious dental issues.
As a result of the audits over $22 prophies, Dr. Meeske said many of her colleagues simply paid the amount requested in the audit and have opted not to take any more Medicaid patients.
Reprinted with permission of  
Copyright © 2014 
This testimony was also featured in ADA’s online news feed:
and in a small online publication called RAC Monitor:
Subsequent to Dr. Meeske’s testimony, Senator Susan M. Collins (R-Maine) sent a letter to the HHS Secretary requesting reforms to the Medicaid RAC audit process.

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