Showing posts with label AAPD. Show all posts
Showing posts with label AAPD. Show all posts

Sunday, May 24, 2015

What are the “Powers That Be” saying when it comes to Medicaid dental fraud and overtreatment?

Below are select excerpts from the transcript and powerpoint slides of a January 2015 CMS Learning Lab Weninar entitled “Advancing Program Integrity for Medicaid Dental Programs: Federal, State and Stakeholder Efforts”.  The Webinar was held by Medicaid-Chip State Dental Association’s (a must check out website) Lynn Douglas Mouden, DDS, MPH, Chief Dental Officer with the Centers for Medicare and Medicaid Services (CMS), (also associated with a host of other organizations). Speakers included:

First, John Hagg, Director of Medicaid Audits, Office of Inspector General, US Department of Health and Human Services, John.Hagg@oig.hhs.gov. His presentation begins on page 3.

Second, Meridith Seife, MPA, Deputy Regional Inspector General, Office of Evaluations and Inspections, Meridith.Seife@oig.hhs.gov, 212-264-2000. Her presentation beings on page 5, about 2/3 the way down the page, and; 

Third, Linda Altenhoff, DDS Chief Dental Officer with the Office of Inspector General, Texas Health and Human Services Commission (THHS). Linda.Altenhoff@hhsc.state.tx.us. Her part of the presentation at the bottom of page 7.

(Bios of each speaker can be found on page 2 of the transcript)

I found a few things troubling, that I’ll discuss later.

Below are the excerpts from Ms. Seife  portion where she speaks about the latest (at the time) OIG Questionable Billing Dental Medicaid Reports:

Who we are:
•The Office of Evaluation and Inspections (OEI) conducts national evaluations of HHS programs from a broad, issue-based perspective.
•We are working on a series of studies evaluating Medicaid pediatric dental services in selected States.

So why are we looking at Medicaid dental services? Well, as I'm sure many of you know, in recent years, there have been a number of high-profile cases where certain dentists and dental chains were found to have engaged in some extremely abusive dental practices. Although such cases represent an extremely small number of bad actors, they can have truly devastating effects on children. Dentists have been found guilty of routinely extracting healthy teeth, performing unnecessary pulpotomies, or putting stainless steel crowns on teeth that didn't need them. Obviously our primary concern is that no kid should ever have to endure unnecessary treatment, or that treatment that doesn't meet basic standards of care. But this can also have a significant impact on taxpayers as well.

The primary goal of our evaluations was to use Medicaid claims data in a way that could accurately identify dental providers who exhibited patterns of questionable billing. We're doing this currently in four states. In 2014 we issued reports on providers in New York, Louisiana, and Indiana. And our California report will be issued early this year. Although we were somewhat limited in doing these studies in only a few selected states, we hope that these reports will serve as a model for how other states can use their Medicaid data to identify potentially problematic providers in their Medicaid programs, and, hopefully, to target their resources more effectively in looking at those providers.

So I've already referenced, a few times, this idea of questionable billing, but I haven't really defined what it means. It's based on a type of analysis that the OID has done in other parts of Medicare and Medicaid, but this is the first time we've applied such an analysis to dental services. What is it? It's really just a method of determining certain billing patterns that are significantly different from one's peers.

We base these analyses on certain key measures that we developed in consultation with numerous experts. We spoke with law enforcement officials who specialized in working dental fraud cases. We also spoke with dental experts in state Medicaid agencies and CMS. We also received a tremendous amount of help from experts within the AAPD and that ADA.

Once we developed these measures, we then analyzed Medicaid's claim data in each state to identify extreme outliers or questionable billers, as we referred to them in our report. Specifically, we use these measures to identify providers who received extremely high payments per child, provided an extremely large number of services per day, provided an extremely large number of services per child per visit, and/or provided certain selected services, such as pulpotomies and extractions, to an extremely high proportion of children.

Once we developed these measures, we then analyzed Medicaid's claim data in each state to identify extreme outliers or questionable billers, as we referred to them in our report. Specifically, we use these measures to identify providers who received extremely high payments per child, provided an extremely large number of services per day, provided an extremely large number of services per child per visit, and/or provided certain selected services, such as pulpotomies and extractions, to an extremely high proportion of children.

Just to give you a sense of what those outliers look like, here is an example of a questionable billing analysis on average Medicaid payments per child by individual dentists. As you see, the vast majority of dentists are clustered around the median and mean amount, with an average payment of about $200 per visit. But, of course, way out towards the left, you start seeing outliers that are very different from that amount. For example, you can see that one outlier was paid over $1,100 per visit on average.

Process for Conducting Audits
•Audit Notification Letter / Entrance Conference
•Define: Audit Objectives, Scope, and Methodology
•Data Collection and Analysis
•Exit Conference
•Draft Report
•Auditee Comments
•Final Report

So, before I get into what we found, I do want to make just a few brief points about our methodology. One of the biggest challenges in conducting this type of an analysis is to be sure that you're comparing similar peer groups. Obviously you don't want to compare a general dentist in private practice with an oral surgeon working in a hospital setting. So, first, we separated out general dentists from other selected specialties. And once we grouped each peer group appropriately, we then established key thresholds for each of the measures.

These thresholds were established using a statistical method that's known as the "Tukey method." For the more statistically inclined among you, it basically calculates values that are greater than the 75th percentile plus three time its interquartile range. For those of you that are not statistically inclined, it's simply a way of identifying really, really extreme outliers. It also does this in a way that takes in the overall distribution into account. It means that you will not just be taking the top ten billers on a particular measure, it has to be significantly different from the norm. As a result, in a number of case, we found no outliers at all for a specific measure.

I should emphasize that this analysis does not confirm that a particular provider is engaging in fraudulent or abusive practices. Some providers may be billing extremely large amounts for perfectly legitimate reasons. Our position is simply that these providers are significantly different enough from the norm that it warrants further scrutiny.

So, using those measures, we identified a number of dental providers with questionable billing in each of the states we looked at. In total, we identified 151 providers with questionable billing, and Medicaid paid these providers over $56 million for pediatric dental services in 2012.

Questionable Billing Examples:
New York :
•Dentist averaged 16 procedures per child, compared with a statewide average of five.
•Dentist extracted the teeth of 76 percent of children he treated, compared with a statewide average of 10 percent.
Louisiana:
•Three dentists each provided an average of 146 or more services per day, compared to an average of 27 services for other dentists in the state.
16.

We also found that a significant proportion of these questionable billers were concentrated in certain dental chains. As many of you know, systemic problems within specific chains is a concern to many policymakers. In the three states we've reviewed so far, between one-third to more than half of the questionable billers worked for certain dental chains. Many of these chains had been previous investigated for providing services that were medically unnecessary or that failed to meet professionally recognized standards of care.

Friday, November 15, 2013

AAPD Behavior Guidance Symposium Nov 2013

According to the American Academy of Pediatric Dentistry, their Behavior Guidance Symposium “kicks” off today at their headquarters in Chicago.  I can simply not believe I was not invited to this event!  I should pay much closer attention to their event schedule in the future.

AAPD BHM Symposium 11-15-2013

Frankly, I’m not sure why the AAPD even has the event, since apparently the AAPD and their “policy and guidelines” are of little value.  According to testimony from ethically challenged dentists involved in various malpractice lawsuits across the nation, he policy and guidelines are mere “suggestions”.

Attending the event will  garner you Continuing Education credits.  With the massive number of dentists working in the Medicaid dental mills, you would think they would need a venue such as McCormick Place or the United Center instead of the Westin Hotel.

Wednesday, July 25, 2012

Dental coalition pressures HHS for a report on sugar-sweetened beverages and it’s affects on oral health.

A coalition of associations and groups have joined together to ask Health and Human Services Secretary, Kathleen Sebelius to commission a report to evaluate the scientific community’s literature and research on sugar-sweetened beverage consumptions affects on oral health.  Story posted at the ADA website.

Why? Do they think someone is lying about sugar being bad for your teeth?

If you google “evaluation of oral effect of sugar-sweetened beverages” I believe you will find this study has been done numerous times! One as late as 2009, heck it’s only 2012. Has sugar changed that much?

Maybe there is a legitimate reason for this request, I’m no expert, nor do I pretend to be. Sound a bit stupid to me, don’t we all know sugar is bad for oral health? Or are we not teaching this anymore?  Maybe this is just something to keep HHS and Kathleen Sebelius’ busy so HHS is not digging into the massive fraud and abuse happening in dentistry today?

Naw, I’m probably wrong, as usual.

No doubt, the American Academy of Pediatric Dentistry (AAPD) is concerned about our children’s oral health, after all they are in front of Congress on a “regularly scheduled basis” with their hand out, telling lawmaker more taxpayer dollars are needed to give children “access to care” so these cavities can be treated as soon as possible. We all know children’s, teeth are highly susceptible to rot over sweets, right?

Heck Bernie Sander’s recently introduced yet another bill to appropriate more money to treat children who they say go to bed at night with “sippy cups” full of Coke.

The issue is so terrible says the AAPD and the Pew Institute that thousands upon thousands of private equity owned corporate dental clinics have spread across the US faster than a Colorado wildfire. All paid for by the taxpayer and all to combat the cavity crisis this country has had since the beginning of time.

Some states such as Texas have doubled their reimbursement for procedures needed to treat these specific problems.

In an effort to end this crisis, the AAPD has turned a blind eye to highly questionable treatment of children’s cavities by dentists, and in many cases have endorsed such treatment – papoose boards, risky sedation etc.

Organizations pleading for the study are:

  • American Dental Association (ADA)
  • Academy of General Dentistry, (AGD)
  • American Academy of Periodontology,

Wednesday, April 11, 2012

Kellogg Foundation v. The AAPD

I don’t know a thing about it, but thought this should be kept around for those “eat your words” moments that usually come up at a later date.   lol

Yesterday the Kellogg Foundation issued a report about using mid-level providers for dental treatment and the American Academy of Pediatric Dentistry responded.  Both are below.  I’m not exactly sure what the issue is with “mid-level” providers. A whole heck of a lot of the Medicaid dentists are barely “mid-level” in training, so that can’t be the issue. (sorry, I couldn’t help myself)

Most comprehensive review of dental therapists worldwide shows they provide effective dental care to millions of children

Suggests greater role for mid-level dental providers in the United States

Apr 10, 2012

Contact: Mary Darby
718.499.0806
mdarby@burnesscommunications.com
Lowell Dempsey
301.280.5741
ldempsey@burnesscommunications.com

BATTLE CREEK, Mich. – An extensive review of the literature documenting care provided by dental therapists and clinical outcomes worldwide indicates that they offer safe, effective dental care to children.  Released today by the W.K. Kellogg Foundation, the study reviews more than 1,100 reports regarding dental therapists and their work in various countries. 
The report documents evidence that dental therapists can effectively expand access to dental care, especially for children, and that the care they provide is technically competent, safe and effective.  In addition, the review also showed that the public values the role of dental therapists and there is strong patient and parental support for their work.

 

Saturday, February 04, 2012

Pediatric Dentistry’s Revolving Door

We hear a lot about the “revolving” door in Washington, but seldom does anyone talk about the revolving door within agencies and professional organizations.  The same organizations that write the rules, regulations, tests, and guidelines that effect each of us in a more personal way. The same organizations that states and lawmakers trust to protect the public from harm. Chances of corruption are 100% when there are no checks and balances.

Their Publications and Studies

Looking are various websites including the American Academy of Pediatric Dentistry (AAPD), you find publication after publication, study after study, dating as far back as the early 1990’s to the present.  Just about all of them are, rewritten and republished studies that are merely mashups of their own previous written articles and studies.

Here is just one of hundreds of examples :

Journal of Dental Education – Vol. 68, Number 1

General Dentists’ Perceptions of Educational and Treatment Issues Affecting Access to Care for Children with Special Needs. 
Written by:
Paul Casamassimo, DDS, MS;
N. Sue Seale, DDS, MS;
Kelley Ruehs, DDS

Referenced:
Casamassimo PS. The great educational experiment: has
it worked?
Spec Care Dentist 1983;3:103-6.

Seale NS, Casamassimo PS. Access to dental care for
children: profiling the general practitioner who treats
young and low-income children.
J Am Dent Assoc
2003;134:1630-40.

If you get to looking at all the professional opinions, publications, studies, and continuing education courses concerning pediatric dentistry, the same names are there over and over.

Saturday, January 28, 2012

Who are on these committees and subcommittees making these guidelines? Who are they cozy with?

 

2011 Behavioral Management Guidelines

The link above contains the latest version, according to the American Academy of Pediatric Dentistry (AAPD). It’s written and revised by the AAPD Clinical Affairs Committee – Behavior Management Subcommittee. I want to know who is on this committees, don’t you?

In fact, I think it is extremely important to know who is on each of these committees and subcommittees. They are setting guidelines and standards that our federal and state government rely heavily on. Most of the time these guidelines are 100% relied upon.

We certainly demand to know who is making our laws and just who these lawmakers are all cozied up with, well, what’s the difference?! NONE!

I’ve found a helpful little website where you can check guidelines for various healthcare professions. It’s at the Agency for Healthcare Research and Quality (AHRQ). It’s the National Guideline Clearing House.

I’ve not tried it, but it appears you can compare guidelines, now isn’t that cool.  Well, if it works anyway.

You can check past guidelines going back to 1997, that seems handy: browse by Organization,Topic,Guidelines in progress, get expert commentaries and much more.

Of course in checking this place out I got fired up over reading all the guidelines for Behavioral Management (D9920). Various terms for it are used; Behavior Guidance, Behavior Management, Behavior Control. The latest term, “Guidance” sounds so much nicer doesn’t it.

I don’t care what they call it, it’s worse than a straight jacket. In a straight jacket you can at least have use of your legs, but not in the papoose board, rainbow wrap, blankets or whatever cuddly term is thrown at the damn thing.