fee-for-service rates, and state law allows managed care organizations to pay the fee-for-service rate to providers that are not part of their standard provider network. It is possible that some of the dentists receiving payments between 100 percent and 102 percent of the fee-for-service rates were not within an MCO’s network. However, some of these dentists were reported by the MCOs as participating providers in earlier years. Our analysis here does not include payments for services through State-Operated Services clinics, Federally Qualified Health Centers, community health clinics, or critical access clinics. However, we estimated that only 18 percent of MA dentists were eligible to receive these supplemental payments in 2011. Thus, for many dentists participating in MA, their maximum reimbursement for some managed care patients was 102 percent of the fee-for-service rates or less.
Similar to our survey question about Minnesota’s fee-for-service base rates, we asked dentists to offer their opinion on the sufficiency of managed care
organizations’ payment rates. More than 84 percent of dentists who contracted with a health plan in 2012 indicated that the payment rates were very insufficient or somewhat insufficient, as shown in Exhibit 2.9. These results are not
significantly different than their opinions of the fee-for-service rates, shown previously in Exhibit 2.6.
Exhibit 2.9: Dentists’ Opinions on Sufficiency of Managed Care
Organizations’ Payment Rates for Dental Services, 2012
To what extent are the health plans’ payment rates sufficient for treating the range of individuals enrolled in Medical Assistance? Do not include critical access
payments, community health clinic payments, or grants in your assessment.
MA Recipient Type N Very Insufficient Somewhat Insufficient About Right Somewhat Sufficient Very Sufficient Don’t Know Children 170 72.9% 15.3% 2.4% 1.8% 1.2% 6.5%
Children with special needs 166 75.3 10.2 1.2 1.2 1.2 10.8
Adults/Seniors 168 76.8 11.3 1.2 1.2 1.2 8.3
Adults/Seniors with special needs 164 77.4 6.7 0.6 1.2 1.2 12.8
NOTES: Analysis represents responses from 170 dentists who reported that they contracted with at least one health plan to provide Medical Assistance dental services in 2012. Percentages may not sum to 100 due to rounding.
SOURCE: Office of the Legislative Auditor, survey of a sample of licensed dentists in Minnesota, 2012.
Earlier we described the state’s use of other, targeted payments to supplement the fee-for-service rates and payments by managed care organizations. The
following two examples illustrate how the use of multiple payment methods requires additional oversight, coordination, and clarification to administer the payment policies. First, many dentists whose clinic received critical access payments said that these additional monies were the determining factor as to whether they continued to participate in MA.
State law allows
managed care
organizations to
pay fee-for-
service rates to
out-of-network
providers.
However,
In 2012, 32 dental clinics did not receive timely critical access
payments, primarily due to deficiencies in one dental administrator’s information technology system.
DHS reimburses critical access dental providers through two different processes. For fee-for-service dental providers, the department provides the 30-percent supplemental payment as part of each claim reimbursement. For dental services provided through managed care programs, each MCO or its dental administrator compiles and submits a critical access reimbursement report to DHS on a quarterly basis throughout the year. DHS then reviews the reports for accuracy, comparing the information to other data received from the MCOs. For payments that are approved, the department then sends funds to the MCOs to be forwarded to the critical access clinics.
For critical access services provided from January through June 2012, UCare, through its dental administrator DentaQuest, was unable to prepare an accurate payment report until mid-November 2012. The problem was primarily due to insufficient programming in the dental administrator’s payment system—
programming that should have been incorporated years earlier.49 The department
concluded that there were enough problems with the data to justify withholding all potential payments to UCare for these critical access providers until it could identify the source and the scope of the problem. As a result of these
deficiencies, critical access payments totaling $625,000 were held back from 32 clinic sites, and the amounts withheld from individual clinics ranged from $15 to more than $180,000. DHS eventually received a satisfactory report for dental services provided in 2012, and subsequent payments were not delayed. Next, one DHS payment policy has not been consistently implemented through managed care organizations. Earlier we described how the department pays community health clinics an additional 20-percent above the fee-for-service rate. We found that,
DHS policies regarding supplemental payments to community health
clinics are unclear and not consistently implemented through managed care organizations.
The DHS payment policy is carried out in accordance with a 1989 session law, but the law is not codified in current state statutes, and the DHS contracts with the MCOs do not require the 20-percent supplemental payment.50 We examined
a sample of MCO claims for commonly provided dental procedures and found that the great majority of procedures provided through community clinics were reimbursed at least 120 percent of the fee-for-service rate. However, payments
49 The reporting problems were first identified by DHS staff in their review of the health plans’ quarterly critical access reports and aided by a review of the managed care organization’s patient encounter and claims data.
50 Laws of Minnesota 1989, chapter 327, sec. 5, subd. 2(b).
Minnesota’s use
of multiple
payment methods
requires
additional
oversight and
coordination to
administer.
for about 11 percent of procedures did not reflect the full 20-percent add-on.51 Unlike critical access payments which are passed through MCOs to clinics, MCOs pay community health clinic add-ons directly from their capitation monies, and DHS does not monitor payments of this type. It is worth noting that as fee-for-service patients were transitioned into managed care in the 1990s and 2000s, DHS incorporated amounts sufficient to support the 20-percent add-on for purposes of developing the capitation payments to the MCOs.
In the previous sections, we examined Minnesota’s various payment policies, rate setting, and how much MA dental providers are reimbursed for their services. Later in Chapter 3, we discuss the impact of payment rates on dentist
participation and MA recipient access to services. We also make several
recommendations regarding the state’s approach to purchasing dental services for the Medical Assistance program. But first, we address several administrative issues that dentists say impact the adequacy of MA payments.