My dillema with medicaid patients in pain ...

[staroceanX]

So I work in a medicaid office and is on production. Here's my dillema:

18 years old Medicaid patient walks in with pain on a tooth, you look at it and you know it's restorable with RCT, post core, and crown. Now, you tell the patient you need to send pre-authorization in order to proceed so medicaid can cover the cost. Pre-authorization has taken from 2 weeks to as long as 6 weeks. So, during the wait, what do you do?

Yes, you can do pulpotomy / pulpectomy and relieve the pain, but medicaid don't pay for these treatments alone. If the RCT came back not covered, you would've done pulpotomy / pulpectomy for free. If you ever worked in medicaid office, you would know this situation happens a lot, doing a few pulpotomy / pulpectomy isn't a big deal, but if you have to do molar ones couple times a day that's a lot of work done for no production. The other option is to give patient pain meds, but are you going to prescribe narcotics to cover up to 6 weeks ? that's a lot of controlled substances to prescribe. Of course we can always take the tooth out, but why do that when the tooth can be saved and the production is more for rct / crown vs. extraction as well. So, this is my dillema, anyone has a solution?

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[Halcion]

So I work in a medicaid office and is on production. Here's my dillema:

18 years old Medicaid patient walks in with pain on a tooth, you look at it and you know it's restorable with RCT, post core, and crown. Now, you tell the patient you need to send pre-authorization in order to proceed so medicaid can cover the cost. Pre-authorization has taken from 2 weeks to as long as 6 weeks. So, during the wait, what do you do?

Yes, you can do pulpotomy / pulpectomy and relieve the pain, but medicaid don't pay for these treatments alone. If the RCT came back not covered, you would've done pulpotomy / pulpectomy for free. If you ever worked in medicaid office, you would know this situation happens a lot, doing a few pulpotomy / pulpectomy isn't a big deal, but if you have to do molar ones couple times a day that's a lot of work done for no production. The other option is to give patient pain meds, but are you going to prescribe narcotics to cover up to 6 weeks ? that's a lot of controlled substances to prescribe. Of course we can always take the tooth out, but why do that when the tooth can be saved and the production is more for rct / crown vs. extraction as well. So, this is my dillema, anyone has a solution?

I know that at least where I work, we do not need pre-authorization if it is indeed an emergency (i.e. patient is in pain). I have take teeth out and started root canals without pre-auth.

 

[staroceanX]

What if after you start RCT and they decided not to cover it? In New York state things have changed, the state no longer sponsor dental care for medicaid patients, they gave the responsibility to the HMOs, so the name is healthplex and fidelis (dental quest) here. So we have seen RCT for young people anterior teeth being denied, it's a for-profit insurance company afterall...

 

[djeffreyt]

In Texas Medicaid does not require pre-auth for Endo, so we don't experience this issue as much. I know that doesn't help. I was going to say you should just do the pulpotomy for free to hold the patient off, but you are right, that would suck to do several a week and have them not end up getting covered, however, how often are you submitting Endo/Post and Core/Crown to medicaid and they deny it? Why are they denying it? Figure out how to make sure it gets approved and this can solve some of the issue.

 

[jacksonkelly]

Here in Virginia we are not required to pre auth rct. But we send pre auth for crown after rct, and occasionally they approve crowns for teeth with large fillings or stainless steel crowns on permanent teeth.
My guess your cases get denied because of the post. What does the denial note say?

 

[staroceanX]

let me get everybody on the same page here, i mentioned on previous post and i will mention it again, for NYS, our governor has decided to move dental coverage for patients with medicaid to private insurance companies in managed care form. Healthplex and Dental Quest are two companies they use at upstate new york. Straight medicaid has a very clear criteria for coverage of RCT / Crown / Dentures, etc. With these new companies taking over medicaid, they do NOT have a clear rule of what is covered and what isn't, all they want you to do is to send in the pre-authorization and they will tell us if something is covered or not. We can NOT predict something is covered or not. so while we wait for the pre-authorization, pt is in pain, and now it ties to my first post about my dillema.

 

[gryffindor]

let me get everybody on the same page here, i mentioned on previous post and i will mention it again, for NYS, our governor has decided to move dental coverage for patients with medicaid to private insurance companies in managed care form. Healthplex and Dental Quest are two companies they use at upstate new york. Straight medicaid has a very clear criteria for coverage of RCT / Crown / Dentures, etc. With these new companies taking over medicaid, they do NOT have a clear rule of what is covered and what isn't, all they want you to do is to send in the pre-authorization and they will tell us if something is covered or not. We can NOT predict something is covered or not. so while we wait for the pre-authorization, pt is in pain, and now it ties to my first post about my dillema.

Unfortunately, it is not your problem. The insurance belongs to the patient and it is their problem. They need to be the one to call and complain that their insurance sucks, they are in pain, and paperwork from a pre-authorization is holding up their care and driving them to the ER to take care of the pain. But the patients are probably too busy tweeting on their iPhones to care. So you need to stop caring. Literally. Present them the options - extraction today or if you want to save the tooth, pain meds while your insurance company processes paperwork to see if they will cover the RCT. If they don't like the options, tell them to call their insurance company.

And good luck trying to get someone on the phone at Healthplex in their government division. So far I swear it's a phantom division.

 

[TJNova2011]

Unfortunately, it is not your problem. The insurance belongs to the patient and it is their problem. They need to be the one to call and complain that their insurance sucks, they are in pain, and paperwork from a pre-authorization is holding up their care and driving them to the ER to take care of the pain. But the patients are probably too busy tweeting on their iPhones to care. So you need to stop caring. Literally. Present them the options - extraction today or if you want to save the tooth, pain meds while your insurance company processes paperwork to see if they will cover the RCT. If they don't like the options, tell them to call their insurance company.

And good luck trying to get someone on the phone at Healthplex in their government division. So far I swear it's a phantom division.

Amen. Tell them to give their "insurance" a holler via 4G.

 

[staroceanX]

I understand what you are saying, and yes healthplex truly surprise us many times in a very negative way in things they deny as straight medicaid would've approved. So if we do what you said, and the patient ran out of pain meds and they still taking forever to approve, patient comes back and ask for more meds, what would you do? prescribe more pain meds? or say no while they cry? (it's also hard to distinguish the difference between the drug-seeking patients vs. the ones that really need some)

 

[J2OS]

Dude... simple answer to your simple question... give the patient the tx options and let them make the decision. If they can not afford the rct they have the option for extraction which should be a covered procedure. If you feel the tooth can be saved and you have a generous bone in your body which I would assume you do given you are a health care provider then you may offer, as mentioned above, a pulpectomy at no charge to tie the patient over. You can also bill the patient for the pulpectomy and in the event the rct is not covered you apply the money to the ext or you can refund the money for the pulpectomy upon approval of the rct. etc etc. Submit for approval and tell the patient that upon notification from insurance company we will know if they will or will not cover rct. In event of no coverage patient will need to make decision to pay or to have extraction.

You seem to be making this more difficult then it needs to be.

In regard to drugs and drug seekers. Look you can not nurse a pt along with narcotic meds. Granted use of pain meds when the patient is in pain is justifiable regardless of if they are an addict or not. However, OTC pain meds are a viable option. IBU 600mg + Acetaminophen 500mg is about the best thing going for dental pain. Once again, in the end your responsibility is to inform patient and let them make decision and extraction is a viable option. If acute swelling is involved, immediate ext or rct is the only option IMHO

The little known fact in dentistry is that everyday services are given away for free. Its the price of doing business.

 

[djeffreyt]

This is a difficult situation, but in the end it isn't your responsibility to deal with these people's insurance and payment issues, nor is it your fault that they allowed their teeth to get to this point. Given the situation you describe, here is what I would do.

Give them their options. Tell them some options need to be pre-authorized which can take 4-6 weeks and still may not be approved. But if they want to save the tooth, that is what needs to be done. You can prescribe some medication for pain, but not enough for 4-6 weeks. When they ask why, explain that is how their insurance company has decided to operate and if they dislike it, they need to complain to their insurance or pay for the treatment and possibly get reimbursed if the insurance company approves of the work and that is their only other option.

Fact of the matter is that this is their issue and they need to pay for treatment if they want it done and the insurance company is in the way. Otherwise, sorry, but it looks like ER visits and meds from ER doctors for them. Besides, I've seen way too many Medi patients with iphones and better sneakers than I own to truly feel that when they say they can't afford something, they really always can't. At Medi rates, a RCT is the same cost as 2-3 months of iPhone bills.