Claims denied

A group of dental surgical centers that treat children and people with disabilities say that Health Plan of San Joaquin (HPSJ) has recently started to deny routine claims for services, and that if it continues they’ll likely be forced to close their doors.

The dispute in San Joaquin County, moreover, may point to broader problems with access to dental care for low-income California children.

Dr. Pankaj Patel, Drs. Larry and Michelle Church, and administrator David Thompson, see about 800 patients a month, some who come from as many as six hours away to their four surgery centers in San Joaquin County. Until recently, they say, authorization for use of general anesthesia was often processed the same day.

“We would develop the treatment plan while the patient was asleep, fax it over, and they would approve it. We would do all the work by the time [the patient was] awake again,” says Michelle Church, who along with husband Larry Church, runs Central California Dental Surgicenter.

Now before HPSJ will give them authorization to use anesthesia, it requires a treatment plan that includes x-rays and documentation that the anesthesia is medically necessary. The providers assert that anesthesia is a must because dentists refer the most challenging cases to their facilities—those who are combative, uncooperative or have a developmental disability and will not sit still during an exam, much less treatment.

“This is the last stop for these kind of kids,” Michelle Church asserts.

“They typically have 10 to 16 teeth that are decayed to the point where we have to restore them or extract them,” says Patel, a majority owner of both Salida Surgical Center and Bay Area Surgical Center in San Joaquin County. Some of the patients they treat are as young as 1 year old, or have conditions such as cerebral palsy, Down syndrome and autism.

September 2014 proved to be a pivotal month in the relationship between the surgery centers and HPSJ. That’s when the latter began denying authorization for procedures perceived as not medically necessary. When the surgery centers complained, they were told that HPSJ was under new management, and the guidelines had changed effective September 1.

The providers say that they didn’t get wind of the changes until mid-September, as their claims started to be denied.

That was the same month that HPSJ became aware, through internal audits, that its authorization policy for use of general anesthesia was not being administered as intended, according to David Hurst, HPSJ’s vice president of External Affairs. That’s when they sought to clarify the process, and the information that the managed-care plan would require, going forward, to make “a timely decision.”

The following month, David Thompson, of Children’s Dental Surgery Center in Stockton, the Churches and Patel met with HPSJ’s leadership team to discuss the current policies. Since then, they’ve traded letters, including one written to the dental providers from HPSJ’s attorneys, which indicates that “behavioral interventions and other modalities” must be tried [by the referring dentist] before anesthesia is used, or claims will be denied.

Additionally, the October 29 letter from Sacramento firm Kennaday, Leavitt & Daponde asked the surgical centers to provide additional documentation that:

–validates when an HPSJ member has a developmental delay, such as autism, or a complex medical condition;

–includes clinical records that document the dental work or procedure required;

–that a credentialed anesthesiologist has given clearance for general anesthesia.

Hurst asserted that “unfortunately, the surgery centers have not consistently complied with the policies, nor submitted supporting documentation.”

The dentists and administrators right to render care—including anesthesia—for a good number of their patients is written into AB 2003, a California law passed in 1998. It approved use of general anesthesia for children six and under; patients with developmental disabilities; and those whose “health is compromised,” such as those with significant tooth decay.

“A patient only needs to meet one of these criteria to be covered under the bill,” says Patel.

For HPSJ’s guidelines regarding children over 7 years old, or those who don’t fall directly within the scope of AB 2003, Thompson says it’s been a challenge to meet documentation guidelines because “they’ve changed multiple times, without input from the treating providers, making it impossible to schedule patients with any certainty that the service would be covered.”

Aside from their experience that its futile to get combative children to agree to have their mouths examined or teeth treated without anesthesia, the dental care providers say the success rate of using other behavioral interventions and modalities is low, and would take an additional half hour to 40 minutes, for which they would not be not compensated.

Denti-cal, the State’s dental program for low-income residents, has not received a rate increase in more than a decade, and last year many of the providers’ rates were cut by an additional 10 percent.

“We’ve contracted with HPSJ for about 10 years,” Michelle Church says, “providing services to their members and never had a problem.” She and her colleagues are frustrated by medical managed care programs that, through their policies have begun to “effectively limit access to members’ care, especially the children who need the services the most.”

The standoff between the surgery centers and HPSJ reflects a statewide trend where access to dentistry under general anesthesia for medically fragile, developmentally disabled, and cognitively impaired children and adults, is in jeopardy, says Alicia Malaby of the California Dental Association (CDA).

The imminent closure of Sutter Hospital and Capitol Pavilion Surgery Center in Sacramento owing to “unsustainably low Medi-Cal and Denti-Cal payments for anesthesia and facility use is just the tip of the iceberg of the ratcheting down of available hospital and surgery center space for dental care,” Malaby added.

In the late October letter, the attorneys asserted that the health plan would require more than a “mere assertion by a dentist that the general anesthesia is medically or clinically required.”

HPSJ has retained board-certified pediatric dentists to review authorization requests for anesthesia use as they come in, Hurst says. The managed-care providers’ policies are intended to protect patients’ safety, prevent overuse of general anesthesia, and avoid unnecessary risks during dental procedures.

The ultimate aim is to have providers use “the least invasive and safest option, “ says Hurst. General anesthesia is a risk at any age, “but particularly for young children.” HPSJ did not note any abuses or overdosing on the part of the providers.

Malaby questions how effective HPSJ’s evaluating dentists could be if they are not on site to see the patient or consult with the referring or surgical dentists.

“Treatment protocols and plans are made by the dentist in conjunction with the patient and/or patient’s family. These are important decisions that need to be made by the professional providers with the most knowledge of the unique and individual circumstances around each individual patient,” Malaby says.

Thompson says he feels that some managed care companies, such as HPSJ, come between doctor and patient. “They’re stepping in the middle of those relationships. A doctor is referring to a doctor [saying], ‘We think this patient needs this,’ and HPSJ says, ‘It’s not necessary, even though we’ve had two doctors who’ve seen the patient.’ ”

To which Larry Church adds: “We’ve successfully treated thousands of underserved children… Now they’re evaluating the cases like we’re not medically capable of making the decision.”

Patel, the Churches and Thompson question whether the newly enforced policies are less about safety, and more about HPSJ’s bottom line.
“The fewer patients you treat, the more money you make,” says Michelle Church.

In the letter from HPSJ’s attorneys, it says that the organization is “dedicated to ensuring that California’s indigent population gets the health care they need.”

But the providers think the policies will have the opposite effect: “Now that [the patient has] found a dentist, the medical managed care is making it impossible for the children to receive proper access to care for their dental needs,” says Michelle Church.

The dentists and administrators of these surgery centers say that with HPSJ continuing to deny their claims, they’re running in the red, and may not be around in six months to treat the lower income population. They’re working with the state to try to get reimbursed, and considering both a fees-for-service rate, as well as an increase in facility fees to meet their expense and overhead.

“If we close… [HSPJ will] pay more for emergency, palliative treatment that lasts weeks and be a lot more expensive than what it would cost to treat and do the restoration in the first place,” says Michelle Church, whose facility is now turning all but the worst cases away. Her facility is now seeking to get authorization through HPSJ on an emergency basis.

The surgery center providers point to a new, December 2014 state audit, which found that a great many of California’s low-income children are not receiving adequate dental care, putting them at risk for lifelong diseases, as a reflection of a downhill trend.

“If these children had access to care at an early age, many would not end up [at our surgical centers],” says Thompson. He, Patel and the Churches say that with the states’ high number of untreated kids, it’s inevitable that more will end up in their chairs—if they’re able to keep their doors open.

“We feel [HSPJ] is not complying by the intent of the law,” says Patel, “and if we don’t get anywhere, we may have to go to court and let the justice system decide this.”

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