Dental surgery centers say health plan is blocking treatment for kids

Three surgery centers continue to struggle with Health Plan of San Joaquin over authorizations for dental treatments for low-income children and the disabled.

The owners of Salida Surgery Center, Children’s Dental Surgery Center in Stockton and Central California Dental Surgicenter in Atwater vented their frustrations in a letter Monday to the Medi-Cal managed care plan.

The owners wrote that patients, including children with autism and other disabilities, can’t be treated because of the inability to receive authorizations from the health plan, which is based in French Camp. Under state law, the health plan is expected to reimburse the centers for anesthesia charges and pay a facility fee.

The for-profit surgery centers treat children under anesthesia because they are too young or have too much dental decay to be treated by a regular dentist.

In September, Health Plan of San Joaquin told the centers they needed to meet requirements and provide additional documentation to substantiate the need for using anesthesia. According to the owners, the managed-care plan previously gave routine approval for their authorization requests and made the payments to the centers.

Health Plan of San Joaquin is the managed care plan for 86,000 Medi-Cal recipients in Stanislaus County and more than 180,000 in San Joaquin County.

“There have been continued conversations and meetings between the plan and the providers on the issue,” said David Hurst, vice president of external affairs for the health plan. “We are trying to make progress to identify what the patient needs are and what are the expectations between the parties.”

Pankaj Patel, co-owner of the Salida center, said the health plan has approved none of the center’s 200-plus requests for authorization since the second week of September. In one case, the center sought approval to treat an autistic child and got a response from the plan that it needed to know the degree of the child’s autism.

“For several patients, we provided all of the required documentation, but the requests still were denied,” Patel said Friday. He suspects the health plan started adding requirements that are impossible to meet in order to cut expenses.

The requirements have included X-rays, treatment plans, clearance from the patient’s doctor and proof of medical necessity to use anesthesia even for severely disabled children, the owners say. The health plan has required proof of diagnosis for children with autism or other developmental disorders.

In addition, the centers are expected to show they tried and failed to modify the behavior of patients who won’t cooperate with dental procedures.

The owners say that without sedation, most of their young patients won’t sit still for X-rays, which are needed to develop a treatment plan. The patients are referred to their centers by dentists because the kids, as young as 4 years old, are unable to tolerate dental care. Many of the children have 10 to 12 cavities and are put to sleep at the surgery centers so they are not traumatized and multiple procedures can be done at one time.

Patel said parents of about 20 children who were denied switched over to the Health Net managed care plan available in Stanislaus County, which is willing to authorize treatment.

Other parents don’t want to part with their children’s pediatrician who participates in the Health Plan of San Joaquin, so they continue to wait for approval. About 80 percent of patients treated at the Salida facility are enrolled with Health Plan of San Joaquin. “We met with the CEO and chief medical officer of the health plan and their requirements remain the same,” Patel said.

Executives with the health plan say they reviewed the authorization process after seeing an increase in requests for treatment at the centers. Hurst said the rules are consistent with state-approved guidelines and the health plan is ensuring that anesthesia is administered to the children for the right reasons.

Dr. Lakshmi Dhanvanthari, chief medical officer, said Friday the plan found there were irregularities in requests and it “also was receiving a huge number of requests. We wanted to make sure we were following the policies appropriately.”

The Salida Surgery Center and Children’s Dental Surgery Center in Stockton treat about 3,000 children each year; the Salida center also treats disabled adults. The surgery centers acknowledge there are risks to using anesthesia, but say the patients have no other treatment options. The children are at risk for severe oral infections if not treated.

The owners have complained about the denials to the state Department of Health Care Services, which is expected to release a fresh set of guidelines next week or in November. The owners hope the guidelines will resolve the dispute with the health plan, though it will depend on the guidelines.

The Salida center began Friday to treat children who are in pain, even if requests for authorization have been denied, Patel said. The business will try to bill the health plan for the facility fees and anesthesia, which can amount to $350 to $400 per case, but does not know if the health plan will pay.

“We have scheduled about 25 to 30 patients next week who are in pain, or have abscesses or lots of cavities,” Patel said. “I don’t want the kids to suffer anymore.”

This story was originally published October 24, 2014 at 8:56 PM with the headline "Dental surgery centers say health plan is blocking treatment for kids."