Presentation to: Dental Advisory Committee
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Presentation to: Dental Advisory Committee

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  • Utilization data continues to be verified. DMAS recently ran and submitted the CMS 416 report to CMS. This report was based on the Federal Fiscal Year 05 - October 1, 2004 through September 30, 2005. Therefore, Smiles For Children data is included in the last three months of the CMS report. In this CMS report, the total number of eligible children who received any dental service during the entire reporting period was 128,217. In the first year of the Smiles For Children program, from July 1, 2005 through June 30, 2005, there have been 145,093 eligible children who have received any dental service. Although there is an overlap in the data reporting periods - July 1, 2005 through September 30, 2005, the data reflects an increase in the number of children accessing care under the Smiles For Children program. There have been 16,876 more children who received any dental service, which is a 13% increase over the CMS totals. There have been 21,833 more children who received a preventive service, which is a 20% increase over the CMS totals. There have been 16,748 more children who received a dental treatment service, which is a 29% increase over the CMS totals. The actual utilization rate or percentage of children in these categories among the total Medicaid population is still being verified. Calculations of the total eligible enrollment have varied and need to standardized between the Doral and DMAS databases. Based on the calculations of services received, Smiles For Children is improving access to dental care in Virginia.

Presentation to: Dental Advisory Committee Presentation to: Dental Advisory Committee Presentation Transcript

  • Presentation to: Dental Advisory Committee August 25, 2006 A New Day For Oral Health In Virginia
  • Pediatric Utilization (Ages 0-20)
    • 16,748
    • 29%
    74,329 57,581 Total Eligibles Receiving a Dental Treatment Service
    • 21,833
    • 20%
    131,319 109,486 Total Eligibles Receiving a Preventive Dental Service
    • 16,876
    • 13%
    145,093 128,217 Total Eligibles Receiving Any Dental Service Total Increase Doral SFY 06 (7/1/05- 6/30/06) CMS 416 FFY 05 (10/1/04- 9/30/05)
  • Enrolled vs. Actively Billing Providers
    • Based on claims paid, the percentage of network providers actively participating in Smiles For Children has increased from 58% to 78%.
      • In the 1 st quarter, 528 providers submitted claims.
      • By the 4 th quarter, 665 providers submitted claims.
    • Enrolled refers to providers that have agreed to participate in the Smiles For Children program, but are not actively participating as evidenced through the submission of claims for services.
  • Distribution of Dental Services
    • Of the 1,391,585 services performed, 951,152 (69%) of services rendered were for Diagnostic and Preventive Services.
    • The balance, 440,433(31%), of services rendered was for Treatment Services.
  • Distribution of Paid Claims
    • Of the $73,184,363 paid claims, $27,004,357 (37%) was paid on Diagnostic and Preventive Services
    • The balance, $46,180,006 (63%), was paid on Treatment Services.
  • Claims
  • Time Frame for Claims Adjudication
    • Average Number of Claims Adjudicated Per Month for the Year: 33,139
      • In the 1 st quarter, the average number of claims processed for the quarter was 20,490 . In the 4 th quarter, the average number of claims processed for the quarter was 40,550.
    • Average Turnaround Time (July 2005 – June 2006) – 19.73 Days
    • 99.8% of all clean claims adjudicated within 30 days of receipt of claim:
      • Performance Standard: 90% of clean claims are adjudicated within 30 calendar days of receipt of claim.
    • 100% of all claims processed within 60 days
      • Performance Standard: 99.5% of all provider claims for services are adjudicated within 60 calendar days.
    Performance Goal: <=30 Days
  • Prior Authorization Activity
  • Summary of Prior Authorization Activity
  • Prior Authorization – Orthodontic Denials First Level Review Criteria Implemented First Level Review Criteria Implemented
  • Call Center
  • Member Calls – Response Times
    • 97% of all member calls received by the Call Center for the year were answered:
      • Total Calls Received for the year = 88,213
      • Total Calls Answered for the year = 85,922
    • The average abandonment rate for the year is 2.2%
    • The average hold time in queue prior to abandonment for the year is 1:07.
    Performance Goal: <=5% Performance Goal: <=3 Minutes
  • Provider Calls – Response Times
    • 95% of all provider calls received by the Call Center for the year were answered:
      • Total Calls Received for the year = 35,294
      • Total Calls Answered for the year = 33,493
    • The average abandonment rate for the year is 4.3%
    • The average hold time in queue prior to abandonment for the year is 4:19.
    Performance Goal: <=5% Performance Goal: <=3 Minutes
  • Grievances and Appeals
  • Member Grievances & Appeals
    • Top 3 Grievance Categories
    • Eligibility (6)
    • Treatment Rendered by Provider (5)
    • Quality of Care (4)
    • Member Received a Bill (4)
    Top 3 Appeal Categories 1. Denial of Orthodontic Services (55) 2. Denial of Partial Dentures (5) 3. Denial of Crown (4) Members submitted 42 appeals to DMAS. In those cases where a hearing was held, the Hearing Officer upheld all decisions made by Doral.
  • Provider Grievances & Appeals
    • Top 3 Grievance Categories
    • Claims Denial (17)
    • Reimbursement Issue (10)
    • Member Eligibility (8)
    • Authorization Denial (8)
    Top 3 Appeal Categories 1. Denial of Orthodontic Services (26) 2. Denial of Upcoded Extraction (3) 3. Denial of Crown (2) DMAS did not receive any appeals from providers.
  • Enrollee Outreach
  • Broken Appointments
    • Doral introduced the Broken Appointment Log at the Spring 2006 Provider Training Session held in March:
      • Broken Appointments are defined as those appointments that are not rescheduled or cancelled in accordance with the provider’s office policies.
    • Broken Appointment Log also featured in DMAS’ Spring 2006 Program Update Memo and Doral’s Smiles For Children Provider Newsletter.
    • Doral’s Office Reference Manual (ORM) updated to include the form.
    A copy of the form can be downloaded from the DMAS website at: http://www.dmas.virginia.gov
  • Dental Check Up Reminder
    • Dental Check up Reminder postcards were mailed to all enrollees with no record of receiving services from July 1, 2005 – April 26, 2006.
    34,443 5,997 June 2006 Roanoke City 2,710 June 2006 Alexandria City 13,293 May 2006 Norfolk City 12, 443 May 2006 Richmond City Total Mailed Month Mailed Area Dental Exam Reminder Postcard Mailings
  • Dental Network Overview
  • New Smiles For Children Dentists
    • Between July 1, 2005 – June 30, 2006, 190 additional dentists enrolled in the program. This represents a 30.64% increase in the network.
      • From 620 to 810
    • As of July 31, the total number of additional dentists that have signed up is:
    • This brings the total number of enrolled providers to 821, which represents a 32.41% increase).
      • From 620 to 821
  • Distribution of Providers By Specialty
  • Provider Recruitment
  • Summary of Key Recruitment Activities
    • Provider Meetings and Office Visits:
      • DMAS and Doral visited more than 130 provider offices located in each region. In the 4 th quarter, various specialty providers such as Orthodontists, Oral Surgeons, and Endodontists were targeted.
        • Application assistance activities (dropping off and picking up applications) implemented
    • Virginia Dental Association (VDA) Component Meetings:
      • DMAS and Doral attended at least one meeting held by each of the VDAs eight (8) components as well as attended the VDA Annual Conference.
    • Old Dominion Dental Society (ODDS) Meetings:
      • DMAS and Doral attended meetings held by two (2) of the ODDS components as well as attended the ODDS Annual Conference.
    • Provider Verification Project:
      • Pre-populated forms mailed to 990 provider locations to verify information regarding the provider name, practice name, office addresses(s), telephone number(s), provider specialty, panel status, office hours, and any other panel limitations as directed by the provider:
        • Implemented production of monthly updated provider directory. Available electronically or printed hard copy.
  • Summary of Key Recruitment Activities (cont.)
    • Strategic Planning with Community Partnerships :
      • FAMIS Outreach Project led by the Partnership for Access to Health Care (PATH), Radford, VA: Collaborated with PATH and provided recruitment materials. Group conducted a door-to-door campaign to recruit dentists in southwestern Virginia.
      • Virginians for Improving Access to Dental Care (VIADC), Richmond, VA: Participated through membership on VIADC and various sub-committees. Quarterly presentation on SFC program updates was added as a standing agenda item.
      • Virginia Department of Health (VDH) Richmond, VA: Provided reports to VDH to assist with monitoring Dentists participating in the Loan Repayment Program. VDH assisted Doral in securing locations for Non-Participating Provider Informational Seminars.
      • VCU Dental School: Conducted brief presentation to 3 rd year dental students. Participated in VCU Clinic Day.
      • Virginia Primary Care Association, Richmond, VA: Participated in annual conference. Primary goals were provider recruitment and increasing program awareness.
      • Virginia Rural Health Association, Blacksburg, VA: Participated in annual conference. Primary goals were provider recruitment and increasing program awareness.
      • Mission of Mercy (MOM): Participated in the MOM-Eastern Shore, MOM-Northern Virginia, and MOM-Wise events. Primary goals were provider recruitment and increasing program awareness.
  • Summary of Key Recruitment Activities (cont.)
    • Communications and Mailings:
      • DMAS and Doral completed several mailings to providers regarding such topics as:
        • Provider recruitment: Letters sponsored by DMAS/VDA/ODDS
        • Fee Schedule Increase
        • Timely Filing
        • Broken Appointments
        • Electronic Funds Transfer
    • Recruitment and Retention Phone Calls:
      • More than 1,000 recruitment phone calls and countless retention calls have been made to licensed dental providers.
  • Current & Future Network Strategies
    • Gap Analysis:
      • Development of provider to enrollee ratios and needs assessment currently underway. Results will identify the adequacy of network and areas requiring more focused recruitment.
    • Non-Participating Provider Informational Sessions:
      • Conduct at least one Informational Meeting per region: Northern, Northwest, Southwest, Eastern, Central
        • Outreach initiated in the Eastern Region (Suffolk).
    • Continue provider office visits and application assistance
    • Continue attendance/presentation at Virginia Dental Association, Old Dominion Dental Society, and Specialty Organization Meetings
  • NEWS AND UPDATES
  • Electronic Funds Transfer (EFT)
    • Doral had anticipated a summer roll-out of the EFT process, but as we delved into the process we learned two things:
      • EFT would truly be a benefit to providers when an electronic remittance would also be available in order for providers to appropriately apply payments.  In order to be most effective, Doral decided it would be best to roll out EFT and electronic remittance at the same time.
      • Significant system development is required to ensure an effective, efficient, error-free transition to these electronic processes.
    • Doral is currently analyzing the project scope and resources. Doral will be working with a vendor on this project. At this time, a Fall 2007 release date is anticipated.
  • National Provider Identifier (NPI)
    • DMAS is adopting the NPI as the standard for identifying all providers on all transactions, including paper.
    • To prepare for the transition to the NPI, Doral and DMAS are targeting January 22, 2007 as the starting date for using NPIs in transactions from providers and trading partners.
    • Beginning May 23, 2007, the NPI is required to be in Doral’s system in order to do business with and receive reimbursement for services under the Smiles For Children program.
      • Currently, 110 NPI forms have been received.
  • Provider Web-Site Enhancement
    • Doral can now receive electronic preauthorization requests directly on Doral’s website or when submitted through a clearinghouse.
      • The electronic preauthorization request must be submitted with the required electronic attachments.
      • Electronic attachments can be sent to Doral Dental using National Electronic Attachment (NEA) FastAttach.
    On-line Authorization Status
  • Fall 2006 Provider Training Seminar
    • Seminar Schedule
    • Monday, October 2, 2006
      • Bristol
      • Roanoke
    • Tuesday, October 3, 2006
      • Charlottesville
    • Wednesday, October 4, 2006
      • Fairfax
      • Richmond
    • Thursday, October 5, 2006
      • Chesapeake
  • Thank You!