The Florida Dental Association is asking DentaQuest to expedite reimbursements for fluoride treatments that have not been paid since January because of company delays in updating its claims processing system.
The issue involves the new ADA procedure codes released in November 2012. The changes included replacing codes D1203 and D1204 (for topical fluoride treatments) with a new code, D1208.
However, DentaQuest, which provides dental care for patients in Florida's Healthy Kids and Medicaid programs, has not revised its internal coverage codes to reflect the changes. As a result, dentists who have been providing fluoride treatments to children in the Florida Healthy Kids program have not been reimbursed since January.
The company expressed regrets for the delay and says the claims will be paid.
In an email statement to DrBicuspid.com, DentaQuest said that implementing the fee schedule for the code changes "has taken longer than we would all like," adding that "claims that have been initially rejected will be reprocessed and paid."
A dentist who treats patients in the Medicaid and Florida Healthy Kids programs provided claim documents to DrBicuspid.com that show that DentaQuest reimbursed the fluoride treatments for patients in the Medicaid program but not for those in the Healthy Kids program.
The dentist, who asked that his name not be used, told DrBicuspid.com that he called DentaQuest in January, February, and March, but he still has not received payments for the Healthy Kids patients. He is one of several dentists in Florida who say they have not been reimbursed by DentaQuest for these patients since the new codes took effect.
The state dental association said DentaQuest should pay the claims and explain the payment delays to providers, noting that the company has had several months to make the necessary code revisions.
"The Florida Dental Association encourages DentaQuest to honor the spirit of its contract with dentists and expedite resolving the reimbursement for fluoride treatment under the new code and without the necessity of resubmitting claims," the association said in a statement to DrBicuspid.com. "The code change was communicated to all interested parties well in advance of its effective date of January 1, 2013. An anticipated schedule and mechanism to resolve these payment discrepancies among all affected providers should be communicated by DentaQuest as quickly and as thoroughly as possible."
The dental association also criticized DentaQuest for contributing to the reluctance that many dentists have about taking patients whose care is paid for by federal- and state-run programs.
"The actions demonstrated by DentaQuest only add to the negative perceptions that many of our members hold about working with government-run programs, such as Healthy Kids and Medicaid, for which DentaQuest is a contracted to provider," according to association's statement. "Fluoride is a key component to preventing the onset of dental disease, and should be encouraged not discouraged by those seeking to advance the quality of dental care."
Reimbursement rates for Medicaid patients usually amount to only 10% to 40% of dentists' actual costs for procedures.
Florida law requires payment of insurance claims within 20 days; otherwise, the insurer must provide an explanation of why a claim wasn't paid.
The dentist interviewed by DrBicuspid.com also noted that DentaQuest will only pay for a full-mouth series of bitewing and panoramic x-rays, which usually includes 16 to 18 images, unless the x-rays are taken during different visits. He said the policy unnecessarily exposes children to more radiation and places an additional burden on them to make two appointments.
The company also bundles the procedures, which results in lower reimbursements, according to claims he sent to DrBicuspid.com.
"DentaQuest follows the ADA and USFDA [U.S. Food and Drug Administration] guidelines on the selection and use of x-rays on children and they do not recommend a full-mouth series of x-rays [Fmx] on children aged 0-5," the company said in a statement to DrBicuspid.com. "With all age groups the guidelines recommend providers select the type and number of x-rays after they risk-assess a patient. These guidelines align with ALARA [as low as reasonably achievable] in that they promote the proper use of x-rays with the least amount of radiation."