WV Medicaid Update
Dr. Carol Buffington, WVDA Representative to Medicaid, and Richard Stevens,
WVDA Executive Director, met with Medicaid officials and representatives of the
various managed care organizations, April 8.  Below is a report of the meeting.
#1    Retroactive to April 1, 2016, Medicaid will pay for D1206, the varnish code at
$20 up to age 21, two times a year.  They will continue to pay the D1208 fluoride
code up to age 21 two times a year.  Dentists cannot bill for both of these codes
within the same time frame; they must chose one of the other every six months.
#2    In regard to complaints by dentists regarding broken appointments (no shows)
by Medicaid patients, WVDA made a “breakthrough.”  Dentists are to file a claim
using the D9986 code for broken appointments, indicating “no fee” on the claim.
In an effort to resolve broken appointments and make beneficiaries more responsible,
dentists are requested to report the broken appointments so the managed care
organizations can hold the patient and family accountable. There is no reimbursement
for this code, but the social workers will be contacting families to see why they are
missing appointments.
#3    WVDA is working on a greater fee for anesthesia services since previous codes
have been deleted and new codes implemented countrywide.  Medicaid divided the
earlier codes by three resulting in $60 for every 15-minute increment.  WVDA has
requested the first 15 minutes be paid at $120 because of expenses of drugs and
other devices, then a reduced amount for subsequent 15-minute increments.
Medicaid officials said they would consider it.
#4    WVDA objected to the nitrous oxide fee being reduced by Molina from $40 to
$18.   This is to be addressed.  No one could site the reason for the reduction.
#5    WVDA objected to The Health Plan denying claims for general anesthesia,
and stating “patient responsible” for the anesthesia in the EOB.  Officials said this
was a covered service, and the matter will be resolved.  (Note: Since anesthesia is
a covered service, dentists cannot legally charge the Medicaid patient for it.)
#6    WVDA requested current “bundling” of multiple services be discontinued.
#7    WVDA requested the following codes be added as covered services: D4212,
D7250 and D9248.
#8    WVDA also reported lengthy delays in dentists being credentialed by Molina
and unable to submit claims.
#9    WVDA reported some dental clinics operated by federally qualified health
centers (FQHCs) were referring patients to private practitioners for certain services.
These are primarily more advanced services with higher values (i.e, root canals).
The referrals began after the FQHCs won their case in court with being reimbursed
on a “per patient encounter” basis instead of a “fee-for-service” basis.
#10    WVDA expressed concern with multiple claims processors causing problems
with verifying eligibility and identifying which plan covers the patient.
#11    Medicaid officials could not comment on MCNA soliciting dentists to sign a
contract since it is attempting to become qualified to administer dental claims
under a subcontract with CareSource — a new MCO attempting to be qualified to
cover Medicaid beneficiaries.