Pankaj Patel, co-owner of Salida Surgery Center, said a parent has waited three weeks for a health plan authorization so her 4-year-old daughter can be treated for abscessed teeth that cause her pain.
Like many young children, the child won’t sit still in a dentist chair and could be traumatized by the extensive dental work she needs. She requires crowns or restorations on 10 of her teeth and was referred to the Salida center by a dentist who was unable to treat her without sedation.
According to surgery center owners, treatment has been delayed for about 400 other low-income children and developmentally disabled adults since Health Plan of San Joaquin imposed new rules for authorizing dental anesthesia for member patients in Stanislaus and San Joaquin counties. Many of the patients are waiting for sorely needed dental treatment at Salida Surgery Center, Children’s Dental Surgery Center in Stockton and Castle Dental Surgicenter in Atwater, the owners said.
Health Plan of San Joaquin says it needs more records to document the medical need for administering anesthesia to these patients. The three centers specialize in treating children who are too young or have too much tooth decay to be treated at a regular dental office.
The children, who may need treatment for a dozen decayed teeth, are put to sleep in the centers’ operating rooms so multiple procedures can be done in one sitting. The Salida center also provides access to care for adults with severe autism, cerebral palsy and other disorders.
The for-profit surgery centers in California were in the spotlight last year when they fought for an exemption from Medi-Cal payment cuts that could have devastated them.
Patel expects it will take weeks to comply with what he calls burdensome requirements imposed by Health Plan of San Joaquin. “It’s just an extra layer of requirements to delay and deny access to care,” he said.
Health Plan of San Joaquin is one of the two Medi-Cal managed care plans serving Stanislaus County, where more than 86,000 residents are enrolled in the plan. More than 180,000 Medi-Cal recipients are enrolled in San Joaquin County, and dental patients in southern Stanislaus County are able to use the Atwater surgery center.
The plan is required by law to pay the surgery centers’ operating-room fees and anesthesia charges, which can be $230 per case and $118 per hour, respectively. The Medi-Cal program reimburses for the dental services.
A spokesman said the plan saw a recent uptick in authorization requests for dental anesthesia and decided to review its approval process. It is making sure providers follow authorization rules that already existed, said David Hurst, vice president of external affairs.
“This is not a financial decision at all,” Hurst said. “It’s about making sure the services rendered are appropriate for the child and the anesthesia is administered to children for the right reasons.”
Three weeks ago, the plan notified the centers they would need to provide X-rays, treatment plans and clearance from patients’ primary care doctors before it would authorize dental anesthesia. In addition, the centers are expected to show that attempts were made to change patients’ behavior so they did not need sedation.
The health plan also wants to see proof that severely autistic patients or others with developmental problems were diagnosed with those conditions. The surgery centers contend that the health plan and Medi-Cal program should have a record of those patients’ diagnoses, especially for those who received authorization for care in the past.
Patel said the younger children and disabled adults referred to his center don’t cooperate with X-rays. For those patients, X-rays are taken and an examination is done under sedation to determine what dental procedures they need.
Muy Ang of Manteca said her 11-year-old daughter, Cienna, always was approved for once-a-year visits to the Salida center for examinations, teeth cleaning and fillings, but has no approval for an appointment Tuesday. Ang said she would prefer not using anesthesia, but her daughter, who is nonverbal and disabled by epilepsy, won’t open her mouth for dentists and may be combative. “She has been putting her fingers in her mouth and I think something may be wrong with her gums,” Ang said. “I am really angry. This is the first time I have had to wait to get approved.”
David Thompson, administrator for Children’s Dental Surgery Center in Stockton, said he received a clarification from health plan staff this week that X-rays and clearance from a primary care physician won’t be required for authorization.
Thompson said the center may be able to live with the remaining rules but believes the hoops are intended to discourage patients’ families. “I have seen this happen in other places. They use the authorization process so it takes weeks to get approval for patients who need care, and the patients give up,” Thompson said.
The Stockton center had 80 authorizations pending this month when the health plan cleared them from its system and required requests to be resubmitted, he said. Some of the center’s anesthesia requests are being approved.
Hurst said the health plan had received authorization requests for dental anesthesia for 330 children since August. That’s about 50 children per week undergoing a procedure that has risks.
Some of the recent requests were from parents who “self-referred” their children to the surgery centers. The requests included social worker referrals and applications without any records demonstrating medical need, Hurst said.
Patel said he talked with the plan’s chief medical officer Wednesday and was not told any rules would be relaxed. The Salida center was able to take X-rays of the 4-year-old girl after 30 minutes of cajoling Thursday. Patel promised to provide treatment for the child today if the mother took the X-rays to the health plan’s office in French Camp and received approval.
Thompson said the Stockton center treats 250 to 300 children every month, most of them from poor families that aren’t being reached by dental care education. He suggested that Health Plan of San Joaquin, a not-for-profit public entity, could budget for sedation services by relying on research, which found that 8 percent of people will need anesthesia for dental procedures and only one-fourth of those will seek treatment.