July 12, 2011 Ms.

Laurie Norris Senior Policy Advisor Centers for Medicare and Medicaid Services 7500 Security Blvd., MS: S2-01-16 Baltimore, MD 21244 Laurie.norris@cms.hhs.gov Dear Ms. Norris: We are writing to you today on behalf of the American Academy of Pediatric Dentistry (AAPD), the American Dental Association (ADA) and our members who provide oral healthcare services to Medicaid and Childrens Health Insurance Program (CHIP) dental beneficiaries. In recent months, a trend has emerged where state Medicaid and CHIP programs seem to be conducting more aggressive audits of dental providers. Our organizations fully recognize and support the need to combat waste, fraud and abuse in the Medicaid program. However, we believe this trend may have a detrimental impact on childrens access to oral health care; the concerns raised by our members may lead to a reduction in the number of dentists willing to participate in Medicaid. Reductions in networks would not only negatively impact a childs access to oral health, but could adversely impact many of the goals identified in the 2011 CMS Oral Health Strategic Plan. Information from several pediatric dentists who are long-time Medicaid and CHIP providers in states including Pennsylvania, New Jersey, and Connecticut outline the concerns. After having undergone an audit, these dentists received audit reports with recommendations that were contrary to the evidence-based clinical guidelines set forth by AAPD. 1 We are concerned about this practice and wish to work with CMS and state Medicaid programs to address this issue. As one example of our concerns, auditors have questioned the use of stainless steel crowns (SSC) as a restorative material, suggesting that multiple surface restorations could have been an alternative treatment. The AAPDs clinical guideline on restorative dentistry recommends SSCs
1

The AAPDs clinical guidelines are developed based on scientific review of the literature, in order to make practice recommendations that promote optimal and effective oral health care for children. Existing guidelines are regularly reviewed and updated, and new guidelines are developed as warranted. The AAPDs Council on Clinical Affairs develops and maintains such guidelines consistent with principles of evidence-based dentistry.

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as an appropriate restorative material for children with extensive decay, large lesions, or multiple-surface lesions in primary molars. Stainless steel crowns versus multiple surface restorations, as the AAPD guideline states, are often the treatment of choice for the Medicaid population because recurrent decay is probable when multiple surface restorations are placed. Additionally, many studies show that the longest lasting restoration in primary posterior teeth is the stainless steel crown. In a demographic population such as Medicaid and CHIP, whose decay and recurrent decay rates have consistently been shown to be appreciably higher than those children from more affluent socioeconomic levels, the use of stainless steel crowns is very often the restoration of choice, certainly superior and longer lasting than multi-surface restorations. The complete AAPD guideline is available at: http://www.aapd.org/media/Policies_Guidelines/G_Restorative.pdf Another example is that auditors have suggested that operating room (OR) cases for children with extensive dental decay should have required pre-operative radiographs in all cases. According to the AAPD, ADA, and the U.S. Food and Drug Administration, Radiographs should be taken only when there is an expectation that the diagnostic yield will affect patient care. In the case of young children, visible decay and/or behavioral presentation is often sufficient cause to warrant OR intervention. This audit recommendation concerns us as we consistently aim to balance the clinical need for radiographs with the potential risks associated with radiation exposure. Additionally, in many cases due to lack of cooperation, it is impossible to obtain radiographs pre-treatment. This is one of the reasons treatment in an operating room setting was chosen in the first place. An additional concern is that some auditing groups do not utilize a licensed pediatric dentist when reviewing clinical charts. The auditors, for the most part, are not familiar with pediatric dentistry, what a proper course of treatment might be, and the unique disease pattern common to the Medicaid population. As you know, the Medicaid pediatric population often experiences a different disease pattern, dietary habits, restorative needs, and health literacy level than populations with private dental insurance. Indeed, many of the cases in question required the child to be treated under general anesthesia due to the extensive amount of dental decay. In some states, it appears that the auditing group (Medicaid integrity unit) is working without communicating or coordinating with Medicaid dental program officials. Of particular concern is the method whereby the auditing entity is reimbursed on a percentage basis. This payment system incentivizes increased findings requiring re-payment of funds. While specific audit findings are being appealed, we fear that aggressive audits performed by decision makers with little or no dental expertise will discourage dentists from continuing to participate in the system and discourage new dentists from treating this population. Clearly, this would be detrimental to a Medicaid dental programs effort to attract a robust provider network essential to meet the oral health needs of Medicaid-eligible children. Our organizations look forward to working with CMS to find a solution and are willing to meet at your earliest convenience to answer questions and discuss possible assistance that CMS can provide. We believe the system would improve with CMS working with state Medicaid agencies and the Medicaid/CHIP Dental Association to ensure awareness of accepted clinical practices in pediatric dentistry, including the appropriate use of peer reviewers (i.e. pediatric

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dentists familiar with Medicaid patients), and require anti-fraud efforts to be coordinated with Medicaid dental programs. We support strong and appropriate efforts to weed out fraud and abuse, but we believe the audit methods described in this letter are counter-productive and may have a detrimental impact on state programs. Should there be questions concerning this letter, please contact C. Scott Litch at the AAPD at 312-337-2169 or slitch@aapd.org and Janice Kupiec at the ADA at 202-789-5177 or kupiecj@ada.org . Sincerely,

Rhea M. Haugseth, DMD President American Academy of Pediatric Dentistry

Raymond Gist, DDS President American Dental Association

cc:

Victoria Wachino, Director of Children and Adults Health Program, CMS Marsha Lillie-Blanton, CMS/CMCS Martha Dellapena, President, Medicaid/CHIP Dental Association

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