Overview
Under Chapter 118E of the Massachusetts General Laws, the Executive Office of Health and Human Services, through the Division of Medical Assistance, administers the state’s Medicaid program, known as MassHealth. MassHealth provides access to healthcare services to approximately 1.9 million eligible low- and moderate-income children, families, seniors, and people with disabilities. In fiscal year 2016, MassHealth paid healthcare providers more than $14 billion, of which approximately 50% was funded by the Commonwealth. Medicaid expenditures represent approximately 39% of the Commonwealth’s total annual budget.
According to Section 420.431 of Title 130 of the Code of Massachusetts Regulations, MassHealth covers preauthorized orthodontic services provided to eligible members. Dr. Sean Willcutts, president of Reen & Reen, DMD, P.C. (R&R), is a certified MassHealth provider with offices in West Springfield, Chicopee, Feeding Hills, and Westfield. R&R received a total of $10,422,021 from MassHealth during the audit period for the services detailed below.
Services Provided by R&R
|
Type of Service Provided |
Amount Received |
|---|---|
|
Orthodontic |
$ 10,380,899 |
|
Preventive |
26,591 |
|
Other* |
14,283 |
|
Diagnostic |
248 |
|
Total |
$ 10,422,021 |
* “Other” includes palliative treatment of dental pain, specialty mouth guards, and additional related orthodontic procedures.
Our audit focused on R&R’s billing practices for orthodontic services provided to MassHealth members, including the following:
- interceptive orthodontic treatment (preventive care)
- comprehensive orthodontic treatment (placing initial bands around molars and affixing brackets and wire, referred to as banding the braces)
- fixed appliance therapy (used to stabilize or align the teeth or jaw)
- periodic orthodontic treatment (quarterly visits once the banding process is complete)
- orthodontic retention/removal (removal of braces and placement of a retainer)
- orthodontic treatment—alternative billing (used when the member has been denied comprehensive orthodontic treatment, but the provider is still paid for the work before submitting a prior-authorization request)
- replacement of a lost/broken retainer
- unspecified orthodontic procedure (only when approved by MassHealth)
These claims totaled $10,380,899 during the audit period and are included under Orthodontic in the table above. See the appendix to this report for procedure codes for orthodontic services.
Orthodontic Services
According to MassHealth regulations, all orthodontic services except for pre-orthodontic treatment and orthodontic retention require prior authorization. Additionally, MassHealth members must be under the age of 21 to qualify for orthodontic services, or must have full banding before their 21st birthday.
MassHealth members can receive orthodontic services when they have a severe and handicapping malocclusion, or defect. These malocclusions include cleft palates, deep impacting overbites, or anterior tooth impactions.1
To receive payment for services, providers must submit a form known as the Handicapping Labio-Lingual Deviations (HLD) Index Form, referred to as the HLD Index, to request prior authorization for comprehensive orthodontic treatment. According to MassHealth Transmittal Letter DEN-87 (dated June 2012), the HLD Index, among other things, provides a single score based on a series of measurements made by the orthodontist that represent the degree to which a member’s teeth deviate from normal alignment. To obtain approval to provide services to members, a provider must report one of the following three conditions on the HLD Index:
- The member has a qualifying condition, such as a cleft palate, deep impacting overbite, or anterior tooth impaction, listed on the HLD Index.
- The member meets or exceeds the threshold score for treatment on the HLD Index.
- The member has another condition, and the medical necessity of treatment is documented in the narrative section of the HLD Index.
Administration of the Dental Program
Under a contract with the Executive Office of Health and Human Services, Dental Services of Massachusetts, Inc. administers the Dental Program, which includes orthodontic services. Dental Services of Massachusetts performs its contractual responsibilities through a subcontractor currently known as DentaQuest, LLC. DentaQuest has both programmatic and administrative responsibilities, including (1) dental/orthodontic provider network administration services, (2) customer service, (3) claim administration and processing, (4) contract administration and reporting, and (5) quality improvement / utilization management. DentaQuest is also responsible for reviewing all prior-authorization requests and HLD Indexes and approving or denying coverage of orthodontic treatment for MassHealth members.
| Date published: | June 8, 2018 |
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