MEMPHIS, Tenn. -- Children in dire need of medical care may be getting denied treatment by the state.
Some African-American dentists say the problem started when the state hired a new TennCare administrator.
Dr. Denise Mustiful-Martin showed WREG pictures of children that were denied treatment because DentaQuest, the company the state hired to run TennCare, said treatment wasn't medically necessary.
The photos show children with brownish-black calcified infections on the teeth, and others show where the gum tissue has grown in between the wires of braces.
Mustiful-Martin showed these same photos to members of the Tennessee Black Caucus in Nashville this week.
She was joined by other African American dentists who hope lawmakers will force DentaQuest to change the way it operates because it cut 200 black dentists from its list of providers.
"We were there on behalf of the children who were not reached. On behalf of the children who will not be reached because of legislation or contractual language in a contract," said Mustiful-Martin.
DentaQuest's contract with the state says it only needs to serve 50.6 percent of at risk children in order to get bonuses up to $8 million a year.
"That's alarming because what happened to the other 49 percent of the children who are not seen?" questioned Mustiful-Martin.
She says African-American dentists are the main providers for families in need no matter the skin color, so some dentists are forced to send patients away.
She believes the patients often end up going to the emergency room where the cost of care is much higher.
DentaQuest shared this statement with WREG late Wednesday:
DentaQuest’s first priority is providing access to high-quality dental care for the 750,000 children who receive dental benefits through TennCare.
In line with our agreement with the state, we invited and contracted with Tennessee dentists to create a new network to meet the state’s requirements for access, while also ensuring maximum quality and efficiency in how members receive, and providers deliver, dental care. We are confident that the dentists participating in this new TennCare dental network will help us to achieve this goal.
Our network invitation process is propriety. We meet geoaccess requirements and utilize propriety analytic tools based on our vast experience in successfully managing Medicaid dental networks across the United States. Ethnicity information is not available to us, and therefore, it’s never reviewed or part of the process.
TennCare certified our network in December 2013 as meeting or exceeding its network requirements, including geographic access. Our network of dentists also exceeds nationally recommended standards for provider to patient access ratios.
No child with TennCare benefits has lost access to dental care. In fact, more TennCare members are receiving dental care as utilization of services, including the number of dental screenings, has increased year-over-year. TennCare members have access to care when they need it. The average scheduling time to obtain a routine appointment is only 11 days as compared to the contract’s requirement of 21 days. For urgent care appointments, the average scheduling time is 23 hours, whereas the contract requirement is 48 hours.
DentaQuest is exceeding every TennCare-established benchmark for network composition, access and outreach.
We are committed to assisting all TennCare members with finding a dentist and have made proactive efforts to communicate with every patient whose dentist was not invited into the newly constructed network. These patients were notified in December and provided with alternative choices of dentists who accept TennCare patients in their area. DentaQuest’s phone number and web site were also included and recipients were encouraged to contact us if they needed assistance with identifying another dentist, if they needed help with receiving care or if they had questions. DentaQuest’s call center also conducted outbound calls to TennCare members. We invite members and their guardians to contact us for assistance by reaching us toll-free at 1-855-418-1622 or online at www.dentaquest.com where people can find a dentist, locate member information or submit a question.
Our attention will always be on TennCare members – meeting their needs now and throughout the length of our contract.
The state of Tennessee responded with this statement:
The Bureau of TennCare entered into a partial risk sharing contract with DentaQuest in October 2013. Under the terms of this business arrangement, the dental benefits manager is incentivized to assure that children have access to needed preventive and treatment services and that care is delivered as economically as possible. Shared savings are contingent upon DentaQuest demonstrating success in both areas – access and cost. It should be noted that not only does the contract create the potential for the dental benefits manager to share in savings, it also creates the potential for the dental benefits manager to share in a financial loss and/or incur other financial penalties if access to care, quality or budgetary benchmarks are not reached.
Contrary to statements that we understand were made at the meeting on Tuesday, there would be no profit sharing at all at a participation ratio of 50.6% or below. This is a misinterpretation of the contract. Whether or not DentaQuest is eligible for shared savings and the amount of those shared savings is determined by a combination of total expenditures and the enrollee participation ratio. Shared savings are only possible if the participant ratio exceeds 50.6%. The level of shared savings would then depend on the amount of savings and the degree to which the participant ratio exceeded 50.6%. The participation ratio is an indicator of access to care and is included in the calculation of shared savings in order to make sure that access to care is not compromised in the effort to deliver care as economically as possible.
As a dental benefits manager for the state, DentaQuest is responsible for creating and maintaining an adequate network of providers. TennCare monitors for compliance with network adequacy standards on a monthly basis. DentaQuest has met network adequacy standards since taking over as the TennCare dental benefits manager.
We prohibit our contractors from any racial discrimination which is a violation of federal law. In fact we require DentaQuest to be an active partner with TennCare in our commitment to diversity. We are not aware of any evidence of racial discrimination in DentaQuest building their provider network, but if we receive any complaints of discrimination we would investigate those complaints. Any specific questions about the formation of the network should be directed to DentaQuest.