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ADA, AAPD call for audit standards

Health care auditing 'on a trajectory'

Washington—American Dental Association and American Academy of Pediatric Dentistry appeals for standardized Medicaid audit procedures reflected one aspect of a deep and rich conversation Feb. 24-25 on the urgent need for collaboration among state Medicaid dental programs, organized dentistry (representing the practitioner) and the federal Centers for Medicare & Medicaid Services.
 
The two-day Program Integrity Summit for invited stakeholders was convened by the Medicaid-CHIP State Dental Association.

"The ADA and AAPD understand the need for appropriate oversight," Dr. Amr Moursi told invited policymakers and stakeholders including dentists, state dental directors, commercial plans, contractors and federal and state fraud and abuse investigators. "But the problems we hear about from providers are that the audits are not taking into account those complexities we talked about."

"Simplify Medicaid administration," said Dr. Kathleen O'Loughlin, ADA executive director, who called for "transparent, fair, consistent, statistically sound audit processes town to town and state to state."

Actually, health care fraud and abuse audits in general are "on a trajectory" and not just in Medicaid and state Children's Health Insurance Programs, said program integrity statistician Bruce Truitt of Third Coast Systems. "The auditing of health care expanded exponentially and more than the system had resources to handle it." And of the many types of health care audits across the landscape of compliance with a welter of federal and state and program-specific laws and regulations, "the RAC is a big game changer," said David Weeks, assistant general counsel in the TennCare Office of General Counsel.

At least 10 states report "recovery audit contractor usage in dental programs" as of Feb. 21, according to a Medicaid-CHIP State Dental Association report included in the packet of materials assembled for the summit: Arizona, Connecticut, Delaware, Kentucky, Louisiana, Maine, North Carolina, North Dakota, New Hampshire and Tennessee. RAC audits in these states were described as ongoing, just beginning or soon to begin, the earliest dating from 2010. Seven contractors were identified.

Recovery audit contractors are contracted by states or managed care entities to search for and recover Medicaid overpayments. One contractor told summit invitees that RACs also seek to redress underpayments.

How many dental audits are there? Dr. Bill Kohn, Delta Dental Plans Association vice president, asked the group several times. "There is no answer to the question," Mr. Truitt replied. "Once is enough," said a pediatric dentist.   

ADA House of Delegates Res. 93H-2013 calls on the Association to:

• "study and evaluate how Medicaid audits are conducted, as well as explore options for improving the current audit system by revising contingency based audits;"

• coordinate development of "a politically prudent, fiscally responsible federal legislative and/or regulatory effort to revise contingency based audits;"

• "advocate for auditing procedures that include appropriate professional review by general dentists, or dental specialists in the case of specialty care, who are licensed in that state," and

• report to the 2014 House of Delegates.

The summit ended with several action steps for follow up by various stakeholders represented. The list included adequate education for Medicaid practitioners so the dentist knows clearly what is expected up front regarding program integrity. The ADA is committed to supporting this effort through in-person and online continuing education for its members.

It was also suggested that quality measures currently under development by the Dental Quality Alliance could be used by state Medicaid programs along with guidelines issued by the ADA and AAPD to provide an evidence base for policies, regulations and benefit designs within state Medicaid dental programs.

At the conclusion of the meeting, participants agreed that detection of waste of finite public dollars in dental Medicaid programs is needed and that the needs of patients will best be met by a dedicated network of practitioners working in collaboration with state and federal agencies rather than as adversaries.