Oklahoma Attorney General Gentner Drummond instructed the state Medicaid agency to withdraw a proposed rule that establishes prior authorization for certain dental extractions.
Drummond said in a letter to Oklahoma Health Care Authority Director Clay Bullard the proposed rule is invalid, alleging that agency staff changed its language twice after it was published for a public comment period from Dec. 15 to Jan. 15. He said the Administrative Procedures Act does not authorize an agency to do this.
“Accordingly, consider this a forewarning that if OHCA does not withdraw the proposal, it is likely only a matter of time before the legislature disapproves it or my office receives a request for an opinion and formally determines the proposal to be invalid and unenforceable,” Drummond said.
Drummond also said the adopted version appeared to give “little or no weight” to the dozens of public comments the agency received.
“Interested parties and affected entities were likely commenting on the text of the proposed rule as published on Dec. 15,” Drummond said. “However, it is clear that the OHCA pulled the rug from those individuals and intended to adopt the rules it and the out-of-state, for-profit MCOs wanted.”
What would the rule do?
The change would impact complex extractions, or surgical extractions, requiring prior authorization if any provider other than an oral surgeon wants to surgically remove more than two teeth in one day.
Through a transition to managed care, or SoonerSelect, the Oklahoma Health Care Authority went from a fee-for-service model, where it paid providers directly, to paying private companies to coordinate some enrollees’ care.
This rule would apply to providers who serve the fee-for-service population, or those on SoonerCare, such as Oklahomans who are aged, blind or disabled, or tribal members who did not opt into SoonerSelect.
But providers serving Oklahoma’s SoonerSelect population, which includes mainly children, pregnant women and Medicaid expansion adults, already operate under a similar practice. The dental managed care entities, including DentaQuest and Liberty Dental, got approval from the state Medicaid agency through a separate process.
Both require prepayment review of claims for surgically removing more than two teeth in one day.
This differs from prior authorization, where a provider submits a request to deliver a service and learns whether a health plan deems it medically necessary or covered before they render it.
Drummond criticized the managed care entities in his letter, referencing his October letter to Bullard, which said providers are detailing alarming trends, including significant reductions in reimbursement for direct pediatric care, payment withholdings and bureaucratic delays.
“It is no surprise that the dental MCOs are behind a proposal that would create more bureaucracy and red tape,” Drummond wrote in his February letter. “Insurance companies are good at denying claims.”
What happened during the Health Care Authority board’s last meeting?
The rule was voted on by the Oklahoma Health Care Authority board during its Jan. 21 meeting, with members Marc Nuttle, Tanya Case, John Christ, Kevin Corbett, Dr. Jeffrey Cruzan and Phillip Kennedy voting in favor, and Vice Chairman Alex Yaffe voting against it. It would have an effective date of Sept. 1, pending approval from the legislature and governor.
In January, Case said the agency’s rules committee did not approve a motion to recommend this rule advance. But Board Chair Nuttle reminded members that it may take whatever action it deems appropriate. He said the board received and reviewed public comments on the rule.
Oklahoma Medicaid Director Melissa Miller said the dental managed care entities brought this issue to the agency's attention. She said the agency looks at what the contracted entities have proposed and compare it to the fee-for-service side to see if it could be beneficial.
“It does seem like there is a large proportion of these extractions being billed as surgical versus simple, more than you would typically see, so there is some concern about potential overuse of these codes,” Miller said.
Reimbursements for a non-surgical simple extraction are approximately $74. Surgical complex extractions come to about $134. Miller said one entity noted it has seen cost savings through their policy, and the agency estimates its rule would result in about $500,000 in savings.
She said the agency received about 80 comments online from the dental community and others opposing this rule, citing concerns about access to care and emergency room utilization.
One commenter, with the first name Nick, said when dental care is delayed, patients often choose the ER, which can be more expensive and less timely. They said rural patients would be the most impacted.
“Added authorization requirements increase delays, travel burdens, and missed work, worsening disparities. This also causes friction between the patient and dentist because the patients are often in pain and want resolution same day,” Nick wrote.” “When we explain to them that we require pre-authorization, frustration mounts and relationships are broken.”
Miller said, in speaking with Oklahoma Health Care Authority Dental Director Dr. Bernard Rhone, the agency doesn’t agree with these concerns.
“We think that [in] the non-surgical setting, it would be rare that you have three or more extractions in that setting, and if there was an emergency basis, we would certainly allow them to render the service and look at the documentation after the fact,” Miller said.
Rhone said they set this threshold so providers in rural settings have an opportunity to cut out two teeth without an issue.
“We're only going to look over your shoulder if more than two are surgical,” Rhone said. “If the other 10 are simple, they can address the patient's needs, and they have full autonomy. What we're trying to do is make sure that when they see the patient, they have a plan in place.”
An Oklahoma Health Care Authority spokesperson wrote in a statement that the agency has engaged in ongoing discussions with the attorney general’s office, it is reviewing the letter and will continue coordinating with the office to determine a path forward.
StateImpact Oklahoma is a partnership of Oklahoma’s public radio stations which relies on contributions from readers and listeners to fulfill its mission of public service to Oklahoma and beyond. Donate online.
