Low participation by dentists has plagued the Medicaid system for years. Despite numerous attempts by the Alaska Dental Society to correct problems Health and Social Services has not made any changes to increase participation levels.
Several factors are responsible for dentists declining to participate in the Medicaid system.
- Medicaid participants failing to keep scheduled appointments
- Chronic drug seeking patients who travel from office to office
- Low reimbursement rates
- “Hold Harmless” clause contained in the Medicaid contract
- “Any Favored Nation” clause contained in the Medicaid contract.
The most common reason dentists give for not participating in the Medicaid system is surprisingly not reimbursement rates, which run approximately 45-60% of standard fees, but the high number of Medicaid patients who fail to keep scheduled appointments. Dental appointments are treatment based, requiring dedicated time from the dentist and staff to provide treatment. Most appointments in medical offices are evaluations and can be double or triple booked. No shows in medical offices can be factored into scheduling; no shows in dental offices cannot. Most dentists are willing to see Medicaid patients, even at the low reimbursement levels, but are unwilling to accept the frustration that comes with patients who fail to keep appointments.
The Alaska Dental Society proposal: create a two part Medicaid system where patients have eligibility for Medical and eligibility for dental. Be willing to remove that dental eligibility for no show appointments.
Patients who invent dental problems to receive pain medication are an additional source of frustration for dentists. Drug seeking patients will travel from office to office using any ruse to acquire pain medication and can become disruptive if not given pain medication. If they are successful in getting pain medication they will continue to call the dental office and the dentist at home to obtain additional medication. Patients can have a large cavity in a tooth without any pain. When a dentists sees a patient who reports pain they generally have to take their word on symptoms. Unfortunately, for the other Medicaid patients there is a larger percentage of Medicaid patients engaged in drug seeking behavior than the non-Medicaid patients.
The Alaska Dental Society Proposal: Create a two part Medicaid system as above and monitor the drug usage of Medicaid patients. If a dentist reports a Medicaid patient they suspect is drug seeking review prescription history and be willing to remove them from the system.
Medicaid reimbursement rates average 45-60% of standard fees while overhead for the average dental office is about 70% of collected fees. The result is time spent for dentists treating Medicaid patients actually cost dentists monetarily. Medical Medicaid reimbursement rates are adjusted yearly while dental reimbursement rates are adjusted on varying spans, the last 10 years ago.
The Alaska Dental Society Proposal: Provide yearly readjustments to the dental Medicaid reimbursement rates.
Participation in the Medicaid system requires providers to sign a “hold harmless” clause. This clause requires the dentist to agree to accept responsibility for both the state and the dentist in the event of a lawsuit regardless of fault. The result is the dentist would have to indemnify the state even if the states actions are the direct cause of a negative finding in a lawsuit. Dentists carry malpractice insurance to provide protection in the event of a negative finding in lawsuit. Dentists should accept the consequences of their own actions but it is not reasonable to expect them to accept the consequences of the state’s actions.
The Alaska Dental Society Proposal: Remove the hold harmless clause from the Medicaid participation agreement.
Participation in the Medicaid system also requires providers to agree to an “any favored nation” clause. This requires dentists to agree to charge Medicaid the lowest fee for a procedure they otherwise charge. The intent behind this is admirable giving the appearance of good consumer shopping on the Medicaid systems part. The idea would be if a dentist signs an agreement with an insurance plan to provide care at a reduced rate in exchange for patients directed to that practice Medicaid would also benefit. The actual result is something else, however. If a dentist reduces their fee for someone who is financially struggling then they would also be required to submit that fee to Medicaid for reimbursement. An example would be Mrs. Jones who is elderly, on a fixed income and needs a new denture. If the dentist discounts their fee 50% then they would be required to bill that reduced fee to Medicaid. Medicaid fees are already discounted severely from standard fees. The additional protection provided by this clause is unnecessary and provides a disincentive for dentists to discount fees to needy patients or participate in the Medicaid system.
The Alaska Dental Society Proposal: Remove the any favored nation clause from the Medicaid participation agreement.