The truth is that Dentists DO accept medicaid and hope the patient never shows up!
REASON : medicaid is HMO so Dentists have patients assigned to their office and if patient doesn't visit office regularly, the dentists still get paid a capitation fee every month. YOU GET IT.. Dentist gets paid every month a few dollars per patient assigned to their office whether the patient shows up or not! if the patient does Shows up then the dentist have to do work approved by insurance and get paid like 15$ for extraction.
lets say insurance pays you $10 per head ( capitation) and you have 1000 patients assigned to your office.. you should be getting about 10K monthly without any work!! but also have to consider that insurance company limits the amount of patients send to your office.. Hope it helped!
Not all state medicaid programs operate in the fashion that you described where patients are assigned to a particular provider and then the provider is reimbursed a flat fee per patient per month.
In CT where I practice, medicaid participants have their choice about what provider they want to see (or that will accept them as a patient), and they aren't assigned to 1 given provider. As a medicaid provider, I can also choose how many (or few) medicaid patients I want to see, and can even be so selective as to restrict the medicaid patients that I see to say kids only, etc. I am also reimbursed by the CT medicaid system on a per procedure, not a per patient system. If I do 4 fillings on a medicaid patient, I bill for, a receive payment for 4 fillings. If I see that same medicaid patient 3 times in one month and do say 10 fillings on them over those 3 visits, I get reimbursed for all 10 of those fillings, not just 1 monthly flat fee.
Where medicaid in CT differs from say a "traditional" private insured patient is both in the fee schedule, the covered procedures and also what procedures need pre authorization. The fee schedule for medicaid procedures in CT is set at the 80% level statewide. Meaning that when they last set the medicaid rates about 5 years ago, the reimbursement rate would be equal to, or above what 80% of the offices in the state would usually get. These rates applied to medicaid enrollees age 21 and under. For those over age 21, the reimbursement rate is 52% of what the under 21 rate is. Prior approval is needed for all endo's, crowns (both of which have approval tending to be based on if the patient has any missing teeth in their mouth), dentures, pulpotomies, stainless steel crowns. The amount of retrospective chart reviews of these patients is also far greater than for a private insurance patient, as well as the number of initial denials that my office receives(even for procedures where there's no exclusionary reason that we can see - especially true for adults). Basically my staff has to do typically 2 to 3 times the amount of paper work that they typically would for my medicaid patients compared to my "private" insurance patients, for less of a reimbursement. As an asside, financially this will often work, as in atleast the area where I practice, the medicaid patients that I treat tend to have a higher decay rate, and as such need more work on a more regular basis than my private insurance and/or self pay patients do. That fact alone allows for the finances to work out since the volume of work is higher, and from an overhead perspective, there's not too much of a difference if I'm doing say 3 fillings vs. 1 filling in terms of how long it takes me and how much material I use, so it can work out. Items like endo's and crowns work financially for those under 21, and for those over 21, my margin is much tighter, but it does work with the fees that CT pays currently.
Not all states have the same system and//or fees that CT does though, and up until a childrens health advocacy group sued the state of CT over the at that time very poor reimbursement rates, things weren't as they are right now. After the state lost the lawsuit and the rates went up to where they are now, CT, which currently has about 2500 licensed dentists statewide, went from have about 150 medicaid dental providers to now having over 1500 medicaid dental providers, and now is in a situation where multiple advocacy groups and the administrators of the program in CT have determined that for kids, there is no longer an access problem, as kids can get an emergency appointment within 24hrs of calling and on average will be offered a cleaning appointment within 10 days of when they call. The state basically made the fees "fair" so that we, the generally speaking small business owners who are providing the care, can see and treat this population of patients in a way that allows us financially to operate our businesses. Is it perfect?? By no means would I say yes to that. But does it work and have more pros than cons?? yes
