In my time as a media professional in the dental industry, I have read a lot of dentist-authored articles about the difficulties of participating in government-managed programs such as Medicaid and CHIP. It’s clear that is a frustrating experience for dentists, who frequently cite abysmal reimbursement rates, huge administrative burdens, and other access-to-care challenges unique to this patient base.
These programs have limited budgets to serve their members, making the issue of fraud, waste, and abuse (FWA) even more of a priority. The Government Accountability Office, for example, found that approximately $36 billion dollars were made in improper reimbursements to Medicaid providers and suppliers.1 Dentistry has had its own scandals in addition to the conviction of individual providers—earlier this year, Benevis, a prominent DSO, settled Medicaid fraud accusations for $24 million dollars.2
So, what’s a dentist who wants to serve the underprivileged—but has bills to pay—to do? There’s not one clear answer. However, new data-driven technologies are offering new opportunities to solve issues that have historically plagued these managed programs. I recently spoke with John Schaak, COO, and Marcel Tetzlaff, vice president of provider experience and benefits management, of Skygen USA, a benefit management solution company.
It was an interesting conversation highlighting how data analysis can help prevent FWA before it gets out of control—or even happens—and how these programs can change the conversation by rewarding efficient and ethical providers instead of only chasing bad apples. The result, they say, is better providers (and a better provider experience) and more money kept in the program for members. Read our interview below.
What are some common issues with managed care organizations (MCOs)? How is Skygen preventing fraud and generally helping the programs provide better dentistry?
John: “Medicaid, CHIP, and other government-funded programs aren’t really insurance. They are budgeted health care. We take a very small amount of money and try to stretch it out over a year for everyone who requires care. With that mindset, we argue that we all have to be the best possible stewards of government programs. We at Skygen sit at the intersection between the states, who are the ultimate owners of these programs, the payers whom they contract with to run and manage the programs (a role we sometimes serve as well), and the providers, the dentists. Our job is to try to make sure that the program is running the best possible way, and that includes not only getting access for those members who need it, but also recognizing providers who are also good stewards of the program and identifying and addressing FWA.
“Important in any program, and especially government programs, is access. We have a very hard time getting providers to participate in government programs because, frankly, the reimbursement is incredibly low compared to what they could be making on the commercial side. And when I say incredibly low, I mean 30% to 40% different. A lot of providers who really want to participate say that ‘It’s just really hard for me to do that, because I’m essentially losing money on the program.’
“There are also lots of administrative burdens that you have to overcome as a provider. The more MCOs you participate with, the more complexity and burden you are adding, because each of the MCOs has their own rules, their own twists on things. We work to try to get MCOs to standardize as much as possible, but it’s a real challenge for providers. What we focus on is how, in order to improve access, we encourage provider participation.
“We start with the state and the MCOs, and we talk about all the different things they can do to make it easier for providers to participate in a government program. Frankly, we talk to MCOs and states about paying providers more. It might sound counterintuitive that I’m saying you should pay providers more, but at the end of the day, you get better providers and less FWA. Those who really want to be in the program get better results.
“There are services that we and others offer that allow providers to streamline what they’re doing, such as our web portal that allows providers to submit claims and receive remittances. There are all sorts of tools that we have available to them. There are program analytics right on the portal, and a one-and-done credentialing service. If the state says, look, this is our credentialing partner, providers go there, they put in their information one time, and the MCOs can come grab it as many times as it needs to be grabbed. Providers are done with that hassle. Same thing with verifying their directory information.
“Overall, though, we don’t focus on FWA exclusively. We talk a little more about our approach, which is to identify and recognize high-quality providers. The implication, obviously, is that conversely, those that aren’t getting recognized are not getting quite the treatment from the program that they’d like, and we also address those folks.
“But the first step is identifying the providers who are good stewards of your program. So, we have a lot of analytics that we’ve built, and a team that does that work to say, here is the behavior that we want to encourage, such as doing a less expensive service. There are some providers who are always choosing a higher-cost service because it’s a fee-for-service program, or there are providers that are doing work that we don’t want them to be doing—restoring a tooth that’s about to exfoliate, for example.
“We have a recognition program that ranges from giving providers a tool that they can put on their website to our smart ‘find a provider’ application. We used to get a lot of calls from members asking for help finding a provider, and the old way was to just send them to the closest one. Now we have this tool where we can identify our providers offering the most efficient care and steer members to them.
“That’s a way for the providers who are doing good work to get more referrals so that they can try to make this Medicaid or CHIP program at least somewhat close to profitable or marginally profitable, so that we keep encouraging providers to be in it, the more access we have, and the more access, the more members go in, the better experience they have, the healthier they’ll be.”
How would FWA have been detected in the past, before you were able to look at big-picture data of what’s happening and who the good providers are?
John: “The old method of managing providers was generating spreadsheets that people would pore over, and to the extent that they could, determine what patterns are there. They would also use what they knew about a particular market for providers. It might be sort of ‘pay and chase,’ so they would pay a claim and have to go after providers to try to recoup that money.
“Our focus is sort of more on preventing FWA, and if we can’t prevent the fraud actually in the office, we can at least at the time when the claim is presented for payment, address it at that point. It comes down to analytics. We have algorithms that are able to identify patterns that we look for with respect to providers, and then things like appropriate care rules. If the provider is going to restore a tooth that we would expect to exfoliate within a month of the restoration, we would then question why that provider is restoring a tooth that’s going to fall out. So, we can address that at the time of payment, and we’re keeping money in the program. The ideal is that you identify patterns. You identify providers who have issues or concerns. You can reach out to that provider group. You can help them change practices.”
Marcel: “A lot of authorizations used to be in place, which was a huge administrative burden for providers. We try to reduce or eliminate those as much as possible, but use these other analytic tools in the system to generally do the same thing. We also look at how far any given provider is from the norm in a particular area—one standard deviation, one and a half, two standard deviations, and then we draw the line on what we consider an outlier based on that analysis. And that becomes almost a filter. From there, we’re drilling down into what may be causing them to be an outlier compared to their peers. And sometimes there are valid reasons for that—maybe they are in an area with fluoridated water, maybe they do have a patient population that has worse health than their peers. Overall, we have a rating tool that measures providers on dozens of different criteria, code ratios, etc. So we’re really looking at providers at many different angles, to try to paint a picture if he or she is performing better or worse than their peers in the same network or area.”
What are some specific examples of FWA Skygen has found?
John: “There’s one that I think is particularly striking. The patient was a one-year-old child, and the claim that was submitted was for 16 extractions—this is real data that we’ve collected over the years. There was no general anesthesia submitted and all teeth were removed by age two. It was a $4,000 claim. A number of things jump up here. Sixteen extractions in one visit is a lot. No anesthesia; that’s awful. Hopefully the provider gave the anesthesia and just chose not to bill for it. I’m not sure if that’s the case. The fact that it’s a one-year-old, probably shouldn’t have that many teeth to begin with. This is likely an instance of just fraud. I don’t know how a dentist doing this would overlook that, but this is what we received. We have a number of types of examples like this—a two-year-old with 16 root canals and 16 crowns and no anesthesia, all in the same day.
“We have a lot of that, but then we have just other things that you wouldn’t necessarily think to look for, but over the years we’ve just kind of identified things such as providers who are not credentialed yet to participate in a given network, so they practice and bill under a different provider within their group who is credentialed. It turns out that the provider that has not been credentialed has an issue; their practices may be questionable. When you’re doing the analytics, this is something that you’d want to follow up on with the group and address.
“We try to avoid, as much as we can, having providers in the network that don’t give the best treatment. What I want to make sure comes across is that the vast majority of dentists in these programs are just saints, if you ask me. They provide services for little to no reimbursement, and the folks who are doing these kinds of things are not the majority. When we go out and talk to providers, I am always encouraged by the level to which providers themselves care about these kinds of issues. It’s counterintuitive, but they really do care about making sure that there aren’t any bad apples in the programs they participate in. So that’s always very encouraging.
“We encourage providers to use the self-service analytic tools we give them, to look at themselves compared to the panel; you’ll see things like this. The provider I have here, the panel is doing about 9.8 stainless steel crowns per 100 members, and this provider is doing 332. Those numbers jump out. Extractions per 100 members, the panel is doing 64; this provider is doing just about 200. Fillings per 100 members, 100 for the panel; 378 for the provider. Pulpotomies per 100 members, the panel is doing is 3; this provider is doing 202. When you get to this data, they’ll all say, look, my practice is different than somebody else’s. I get really hard patients. But when you look at the numbers, and they’re so far off from what the panel is doing, you can say to the provider, look, this is the population that all these providers are dealing with. This is what the panel does. Your experience is just really out of whack. And there’s something that needs to be addressed there. We always want to ask questions and not assume something just based off the numbers, but that’s always a very good place to start to identify where someone needs help.”
Marcel: “We’re also looking at the underutilizers, because that is a problem as well. We’ve given great examples of the overutilizers, but there are also instances of providers not providing the total gamut of care that they should be. We don’t want to remove providers from the network. We are trying to educate them and let them know where they are in comparison to their peers, and figure out why they land where they do land. And hopefully that will encourage them to provide better and more effective care. And I’m very passionate about that. A lot of people talk about lower cost and higher quality, and some people may say that it is not achievable, but our data shows that it is. And typically providers who are providing better care are also providers that have a lower cost per patient, so it’s really a win-win all around for everybody that’s involved in the care of these individuals.”
John: “One thing that’s very important for providers to understand is we do look at underutilization, especially on preventive services. We don’t assume and do not agree with the idea that less care or less costly care necessarily means better care. There are times when more care is appropriate or needed, and it’s not being provided. We also build that into our provider rating program. Our criteria look at restorative and preventive procedures, a number of different measures, including underutilization. At the end of the day, what sometimes we will hear is, if you keep costs down, that’s just saving more money for your client, and that’s not the case. All of our clients are dealing with medical loss ratios that they need to meet. So, they can only spend so much money toward their administrative services, and a certain amount of money they get from the state needs to be spent on the benefits that are provided to members, so they’re sort of capped at what they can make. So, every dollar we keep in the program is a dollar that is potentially being put back toward the benefits.”
What common objections do providers and potential providers have? What should they reconsider?
John: “A big part of it just comes down to reimbursement in dollars and cents. Can it be a profitable program for providers? If you’re using the tools at your disposal and partnering with MCOs and with a company like Skygen, it can be a very profitable and rewarding program to participate in.”
Marcel: “We don’t hear objections to our data analysis too often, but when we do, I say to providers that you want us to be doing the analytics that we are doing. Because a big part of this is the fact that this is a provider reward system as well. If we identify you as one of those providers who is providing appropriate, quality care in a cost-efficient manner, you will be recognized. Recognition can be either financial or being able to publicize that on your website or office, or having members steered toward your practice. We’re helping you grow your practice if you are one of those providers on the good side of the spectrum. Again, most providers that are not performing as well can certainly improve, and we can work with them to improve and get them to be better-performing providers. We have staff, or our MCO clients have staff, that are out there talking to these providers every day. We have clinicians that are available for peer-to-peer conversations as needed, so it’s a two-way communication, and we are all just trying to work together to achieve better results for the program and for the patients who are a part of these programs.
“The most recent provider issue that we were involved in started about two years ago. There are four MCO clients in the Medicaid program in West Virginia; all of them are clients of ours. There was a provider there by the name of Antoine Skaff. We started our investigation about two years ago, and after several months of doing an audit, we are required at some point to turn it over to the state depending on our contract with them. We ended up turning it over to the state, and they looked at our data and raided the office. Just a couple months ago, Dr. Skaff was convicted and sentenced to five years in prison. Those things happen, and that’s a part of why we do what we do day in and day out, but hopefully those are few and far between. Even though it’s good that we caught that, we prefer to just get providers to behave in an appropriate manner so that they’re not caught in the worst-case scenario of being convicted of FWA.”
John: “That is an unfortunate part of these types of programs, but coming back to what happens with Medicaid and CHIP programs, because the reimbursement is so low, the experience historically had been challenging from an administrative standpoint, which we try to address. You’re sometimes only left with providers who need work to do. We really focus on how we can ultimately make this more profitable for providers and increase their reimbursement, so that you’re getting not only those who have no other choice to participate, but a broad spectrum of providers, and you can ultimately deliver better care. There is a difference between providers at some level, and we want to encourage as many good providers to participate as we can. That’s why it’s so important to manage the money.”
1. LaPointe J. GAO finds $36B in improper Medicaid reimbursements in 2016. RevCycle Intelligence website. https://revcycleintelligence.com/news/gao-finds-36b-in-improper-medicaid-reimbursements-in-2016. Published February 1, 2017. Accessed June 12, 2018.
2. Brasch B. Cobb dental company will pay $24M after accusations of Medicaid fraud. The Atlanta Journal-Constitution website. https://www.ajc.com/news/local/cobb-dental-company-will-pay-24m-after-accusations-medicaid-fraud/RrZG1JJ94GkXwqGiFov1TJ/. Published January 11, 2018. Accessed June 12, 2018.
Amelia Williamson DeStefano, MA, is an associate editor in the PennWell Dental Group working on Dental Economics, RDH eVillage, RDH magazine, and Apex360.