Remember we wrote that Texas should watch out for DentaQuest and its corporate behavior, which cost the company $11 million in Louisiana fines for Medicaid contract violations, which was recently reported in a report by the Louisiana Legislative Auditor’s Office.
DentaQuest’s recent history has been poor
The report noted that “providers noted continued problems with claim denials. Some providers reported that denials are inconsistent with current best clinical practices and guidelines and are the opposite of what is taught in dental school residency programs. One provider said, “The perception is that they’re looking for ways to save money so they can show the state that they’re saving, but they’re denying medically necessary and necessary care.”
TDMR also reported that Massachusetts gave DentaQuest the boot this year after its long-term contract ran out as the state’s third-party payer ran out and replaced the company with Benecare. There were many complaints state dental groups, incl allegations of medical discrimination, access-to-care violations, and quality control failures;
Financial problems affect the parent company, vows change
That dismal performance has weighed on its bottom line and upset its Canadian parent, Sunlife, with its CEO promising changes.
in May, Reuters reported that Sunlife had its first earnings loss in 12 quarters due to a 20% drop in DentaQuest earnings in the first quarter of 2024.
Importantly for Texas Medicaid providers, Sunlife CEO Kevin Strain had this to say:
“Medicaid enrollment in Sun Life’s U.S. dental insurance plan has declined since the end of the COVID public health emergency last year, and costs from remaining members have increased. Strain said the company is now is negotiating higher payments from states, with about 25% of its Medicaid business already priced close to the company’s pricing targets and the remainder expected to be priced by the end of the year. [emphasis TDMR]”
Changes in Texas
Rumor has it that there has been turmoil at the DentaQuest offices in Texas, and Texas is apparently at the end of one of those “pricing targets.”
Surprise! DentaQuest stops paying for two surface fillings
As of June, DentaQuest has been telling Medicaid dentists in Texas that it will now only pay the single surface price for two surface fillings that are not connected to each other, arguing that this is an industry standard.
One provider told TDMR, “DentaQuest degraded the fillings of two surfaces and paid the price of one. They only pay for two surfaces if they are between them. When we asked for data to support this practice—as no other security does this—they claimed it was “industry standard.” It’s the first time any of us have heard of something like this.”
One dentist told TDMR, “The rationale that they’ve come up with it has been constantly changing over the last few weeks. Their first explanation was that OL and OB are not considered Class 2 restorations like MO and DO restorations, so they will be paid as Class I. This explanation was particularly troubling because it was shockingly uninformed. Such a big company couldn’t understand it “Class 1” and “Class 2” are part of the GV Blacks classification and have nothing to do with billing codes. Dental billing codes have always been based on the number of surfaces a restoration touches. The GV Black classification does not apply… After that they adjusted their explanations, basically saying that OL and OB are not time consuming and therefore they are only going to pay for them as one surface. Again, an absolutely awful explanation that makes their ‘undercoding’ look like nothing more than theft in plain sight.”
DentaQuest as DMO is paid by Texas per member, per month. So this is a clear cost-cutting measure on the backs of Medicaid providers to help their parent company meet profit targets. Who Said Canadians Were Nice?
More bad news for dental providers
As Texas providers continue to be hit by the dental staffing crisis and inflated supply prices, this is just another nail in the coffin for dental Medicaid in the state.
As one provider commented to TDMR about their struggle to keep alive, “We’re struggling to keep our staff. Our personnel costs are significantly higher than the upper range of estimates in the article. Our lease is up soon. We are considering moving to a more affluent part of town and no longer accepting Medicaid, selling or simply closing.”
And another, “We are a Medicaid children’s dental provider in Texas and we are having an amazing time keeping up with Medicaid reimbursements versus the cost of running and staffing a dental office – Unless TX raises fees and keeps up with inflation – kids on Medicaid in their state Texas will suffer as they will NOT find providers readily available to treat this high-risk patient population.”
How will Texas HHS respond?
We’re told that several providers have complained to Texas Health and Human Services about this DentaQuest pricing maneuver. Some even approach CMS at the federal level.
As far as we know, there has been no response yet. We certainly hope it’s for the benefit of the providers, not a large insurance company trying to please its parent company or set profit targets.
Oh yes, will there be an increase in dental fees? That’s the big question for Medicaid dental providers, too.
