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Thomas Suehs
Executive Commissioner

Date: August 30, 2011
Contact: Stephanie Goodman (512) 424-6951

State Takes Steps to Improve Oversight of Dental Services

AUSTIN – The Texas Health and Human Services Commission (HHSC) is taking several steps to strengthen the authorization process for braces while still ensuring that children on Medicaid are able to get all medically necessary services.

“Texas has done a good job of increasing access to dental care, and we want to continue the momentum in that area,” said Texas Health and Human Services Executive Commissioner Tom Suehs. “But we also need to make sure that every dollar we spend is for services that are medically necessary.”

The 2007 Texas Legislature approved a 50 percent rate increase for dentists to help expand access to dental services for children on Medicaid. Since that time, the number of children getting dental care in Texas has risen from 45 percent in fiscal year 2007 to 63 percent in 2010. Spending on orthodontic care in Texas has increased from $102 million in 2008 to $185 million in 2010.

“We know that when you increase the number of children getting dental checkups, you’re going to see an increase in expenditures for related services because we’re finding and treating problems,” Suehs said. “But I’m concerned that some requests for braces may have been approved in cases where state policy wouldn’t cover that service. If that’s the case, we’ll get that money back for taxpayers.”

HHSC is making several changes to tighten the enforcement of Medicaid dental policies:

  • The contractor responsible for approving requests for orthodontic services has been directed to develop a corrective action plan to ensure that existing state policies are followed. Those policies limit orthodontic services to cases where it is medically necessary. State policies do not cover orthodontic care for cosmetic reasons.
  • The contractor has hired a new dental director and added two more orthodontists and 10 additional staff in its dental unit. The orthodontists will join two other orthodontists under contract to review requests for orthodontic services. Staff in the unit also will receive new training to ensure they are following state policies when reviewing requests for services.
  • On Oct. 1, the state will begin requiring full-cast dental molds to be submitted with all requests for braces. This is in addition to the X-rays, photos and other documentation already required.
  • The state has begun pulling hundreds of cases to review the contractor’s approval process for braces. The state will sample new cases each quarter to review the work of each staff member processing requests for services.
  • The state Office of Inspector General is continuing its review of the authorization process for orthodontic services.

If the reviews find that the contractor approved services that don’t meet the state criteria, HHSC will recover those costs from the contractor. If the state finds cases where a dentist or orthodontist submitted incorrect information in order to get services approved, the state will seek reimbursement from the provider. Any cases involving suspected fraud will be referred to the Office of the Attorney General.