Rural kids’ dental care is suffering under new Medicaid policies, dentists say
Pediatric dentists in Alaska say they are facing serious problems with Medicaid paperwork since the state changed its policies on service authorizations last year. Those providers are worried that kids in rural Alaska are losing access to care.
“It’s worse than we would have even been capable of imagining,” said Meghan Foster, of Denali Pediatric Dentistry in Anchorage.
In December 2022 the Alaska Department of Health, or DOH, introduced new regulations for Medicaid coverage. As part of those changes, dentists must now seek prior authorization for pediatric procedures under certain conditions—for example, when a child needs three or more teeth to be extracted or crowned in a single appointment, or when a kid needs more than four extractions or four or more crowns in a single year.
Pediatric dentists had warned DOH that these changes would create a burdensome influx of paperwork due to the high rates of dental decay among kids in the state. But the department dismissed those concerns and promised three-day turnarounds for service authorizations. More than half a year later, dentists say it’s rare for authorizations to be returned before treatment, their claims are being wrongfully denied, they’re waiting for payments and their offices are struggling to keep up with paperwork.
“We are seeing four weeks minimum, every single thing we’re doing, whether it’s a service authorization, whether it’s submitting for payment, and then —God forbid— if Medicaid is the secondary insurance, that’s a rabbit hole we can go down,” Foster said. “Every single correspondence, it’s four weeks for any return of information. Instead of managing the office like she has done for the last 13 years, my office manager’s entire job is trying to play by Medicaid’s rules to get paid. We have no other time for her to do anything else basically.”
The policy changes came in response to recent legislative audits that found instances of apparent overuse in the Medicaid system. For example, a 2019 audit found 60 cases of recipients getting five or more crowns on the same day. But some dentists say the audits failed to look at the reasons behind these high numbers. Foster said that seeing kids coming to Anchorage from villages off the road system with eight, 12 or 16 teeth that need treatment is an average day in the office. Approximately 100,500 Alaskans aged 18 or younger are enrolled in Medicaid, also called Denali KidCare. The program covered two-thirds of American Indian and Alaska Native children in the state as of 2017, according to the Kaiser Family Foundation.
“For someone to look at the averages for the state of Alaska and say there has to be abuse going on, that’s someone that hasn’t looked at how high our decay rates are,” Foster said. “We have the highest decay rate, so we’re going to have the highest restoration rate. These kids don’t have access to follow ups, so those teeth are going to get crowned when there’s cavities on them.”
Foster said the issues go beyond new administrative headaches and delays in payouts for dentists. Some kids off the road system are too young or too anxious to receive treatment or even get X-rays without sedation. They might need to travel to a city like Anchorage to go under general anesthesia. A holdup in service authorizations can lead to holdups in travel authorizations.
“If the parents can’t get the insurance lined up, then they can’t get the travel to come in, then they can’t get the treatment done,” said Foster.
Some kids in the Norton Sound region are referred to Bitesize Pediatric Dentistry in Anchorage. Josh Mize, who handles the paperwork for the practice, described a case in which a kid from a village in the region was in “pretty severe pain” while waiting to travel to Bitesize for care. But as the child’s appointment date was approaching, Medicaid still had not approved the travel.
Without prior authorizations, many dentists choose to administer the care needed anyway out of an ethical obligation to patients. They hope they’ll eventually get paid by Medicaid in the future. It’s a different calculation for a family on Medicaid who might not have much income to spare. In the case he described, Mize said the child’s parent patched together funds and paid for the trip out of pocket without knowing if or when they would get reimbursed.
“We’ve had that happen multiple times,” Mize said.
The cost of a trip to Anchorage, especially in the summer, easily climbs into the thousands of dollars. The roundtrip flight from a village to Nome on Bering Air for two costs upwards of $600. The roundtrip flight from Nome to Anchorage on Alaska Airlines for two also costs upwards of $600. If the patient and adult escort don’t have family or friends to stay with in Anchorage, a hotel might cost $300 per night.
“A lot of parents are frustrated, because it’s not how it used to be,” said pediatric dentist Samantha Mize of Bitesize. She noted that there have always been issues with travel even before the changes. For example, it’s become increasingly difficult to find hotels that will accept Medicaid during the summer when they could make more money off tourists. But she’s worried that the problems will go beyond travel woes if the current dysfunction continues. Mize said that providers in the dental community are talking about dropping Medicaid if they continue having to wait for tens of thousands of dollars that Medicaid still owes them.
“If Medicaid doesn’t start paying these providers, we can’t pay our staff, and people are going to stop being Medicaid providers, and then the barrier to care is going get even worse,” Mize said.
The state’s Medicaid system has no electronic option for filing service authorizations. They must be submitted by fax or mail, which makes them hard to track. And when providers in Anchorage file service authorizations for their patients referred to them from places like Nome or the surrounding villages, they do so blind; without seeing the patients first, they must guess at a treatment plan based on what dental assistants or other providers report. Sometimes those kids are too squirmy or anxious for a provider to get a good look for an assessment. If that treatment plan changes during the procedure, that’s another round of paperwork. And then if those treatments are denied coverage, more paperwork is required to appeal the decision.
“Even if it’s perfect, if my treatment plan didn’t change and we have a pre-authorization, there’s still denying those claims, and we’re still having to appeal them, because they have not trained staff at Medicaid to understand the rules,” Samantha Mize said.
For instance, she said they’ve had claims denied for patients who needed four or more crowns in a year.
“We got denied because they said, ‘You’re not allowed to do four crowns in a year,’” Mize said. “So there is an absolute misunderstanding of the actual rule. If a child needs a certain amount of crowns, we can do that. The rule is that you’re supposed to pre-authorize it. But we have someone over here at Medicaid that’s now going through and denying all of these claims that have already been pre-authorized. We’ve already gone and done all the paperwork that we need to do, and their complete lack of understanding is now making it to where we’re not getting paid.”
The service authorizations also bring new headaches to dentists who work in villages.
Christine Roalofs is a pediatric dentist who contracts with Norton Sound Health Corporation. If she’s visiting a village like Stebbins for just a week, she doesn’t have time to wait for pre-authorizations to administer care. She said she experienced long delays in getting retroactive authorizations, and she’s still waiting to get paid for extractions she performed in February.
She attributed some of the confusion to the state switching contractors to manage its Medicaid system this year. In April, Health Management Systems (HMS), a Gainwell Technologies company, took over for Conduent State Healthcare. Handling authorizations is one of the jobs that this contractor does.
Shirley Sakaye, DOH director of communications, responded to questions from the Nugget by email, confirming that there had been a backlog in service authorizations.
“We take the dental health of children in our state very seriously and are working with HMS to ensure the dental community receives timely service authorizations to treat their patients,” Sakaye said last month. “Since HMS assumed these responsibilities, it has experienced a larger than anticipated number of dental service authorizations.”
Sakaye said the department receives and continues to process about 600 pediatric dental service authorization requests per month, representing 37 percent of all dental service authorizations.
To address the backlog, Sakaye said, DOH has done the following: A separate email address has been launched to specifically handle prior authorizations for dentists whose patients need urgent care. Since the transition in April, HMS has doubled its dental service authorization staff to a total of nine people. HMS is currently onboarding another five staff members to process the backlog and to deliver ongoing dental fiscal agent services. HMS is working collaboratively with the department to streamline the entire service authorization process. In a follow up email on Aug. 10, Sakaye said that pediatric dental authorizations are being given the highest priority.
She added that the state is working with HMS on “several concurrent initiatives” to reduce the administrative burden and processing times. They have promised new request forms specific to common procedures by Aug. 18, as well as a new Dental Services website by the end of the month. They also promised a revised Dental Billing Manual “to add clarity to service authorization requirements and processes.” Sakaye said an announcement about these changes will be published in the Aug. 16 Remittance Advice.
The spokesperson recommended members of the pediatric dental community to join the Medical Care Advisory Committee, MCAC for short, a group that advises the State’s Medicaid agency, including program improvement recommendations. “The MCAC Dental Subcommittee has met a few times since the regulations were adopted in 2022,” Sakaye said. “They made several excellent recommendations to the Department, most of which have already been implemented.”
Many dentists have aired their concerns, both before and after the rollout, including at a Zoom meeting the MCAC held last fall.
“They basically told us that we’re not going to change the regulations, the regulations are in place, and they are moving forward,” said Roalofs who was present at the meeting.
She said she was in support of Alaska making some changes to help root out fraud. There was a recent spotlight on problems in the system’s oversight when Anchorage dentist Seth Lookhart was sentenced to 12 years in prison for charges including Medicaid fraud. He also filmed himself performing an extraction on a sedated patient while riding a hoverboard. But Roalofs said she wished pediatric dentists had been consulted before the policies changed. Still, she’s holding out hope that the state can turn things around.
“I just really hope that Medicaid can get this fixed,” Roalofs said.
If you are a Medicaid recipient and have experienced new delays or obstacles in getting dental care for your kids, the Nugget would like to hear from you. Please send a message to reporter Megan Gannon at news2@nomenugget.com, or call or text her at 907-434-6339.
The story is an updated version from the print edition, reflecting changes of additional comments from the Dept. of Health.