Making Medicaid Dental, Vision More Expansive Doesn't Have to Mean More Expensive


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By all accounts, healthcare was the #1 driver of the results of the recent midterm elections. While the primary focus was preserving the gains that have been made in bringing health insurance to more Americans, especially those with pre-existing conditions, it appears there may have been some positive unintended consequences.

As a result of changes at the state level there is a strong possibility that Medicaid expansion, will come to states where it was previously not pursued. This includes the addition of dental and vision care for children under the age of 18 per the Essential Health Benefits provisions of the Affordable Care Act.

With the sweet, however, comes the bitter, because states must now determine how to pay for this expanded coverage. Federal money will cover most of the initial cost, but there is a sliding scale that shifts more of the cost to the states in each successive year. With many states already struggling to cover the cost of their current Medicaid programs, finding the money for expanded dental, vision and other coverage presents a significant challenge.

Rather than following the usual government solution of appropriating more money, which can be difficult politically (especially in these contentious times), a better approach is to use technology and automation to drive down the cost of managing benefits. In doing so states, payers, managed care organizations (MCOs) and Third-Party Administrators (TPAs) can make more money available to meet the care needs of the expanded Medicaid market. Following are some proven technology-enabled strategies they can pursue.

Attract and retain more high-quality dental and vision providers to the network
Because Medicaid typically pays pennies on the dollar compared to commercial dental and vision plans, it can be difficult to attract enough providers to deliver high-quality care to all who need it. Some of this economic disparity can be made up with higher patient volumes and shorter patient visits, especially when treating young children with less acute needs. The challenge becomes to retain providers once they are there.

Technology-enabled solutions can make Medicaid programs more attractive to more dental and vision providers by removing much of the administrative burden while increasing patient volume. Examples of improvements include:

  • Creating a single login to a centralized hub to replace multiple logins and security protocols across different payers, MCOs, and TPAs.
  • Making complete, accurate benefit coverage and cost information available instantly online to eliminate time-consuming eligibility verification telephone calls. Everyone wants to know they will be paid for the care they render.
  • Returning medical necessity decisions from any participating payer in minutes, improving revenue streams. This capability will also improve patient outcomes by allowing treatment to be scheduled while the patient is still in the office, significantly reducing the risk of postponed procedures.
  • Evaluating and adjudicating proposed services in real time to offer feedback about potential reasons for denials so informed decisions can be made before care is rendered.
  • Using technology to generate instant explanations of benefits (EOBs) that help patients/members understand if there are any uncovered charges so providers can collect at the time of service. If providers are registered for electronic claim submission and payment, payers, MCOs, and TPAs can enable same-day payment of the Medicaid portion, further improving cash flow.
  • Leveraging national credentialing and provider data management services that enable dental and vision providers to submit information one time and have it accessed from a centralized database rather than having to submit information to each individual payer, MCO, or TPA.
  • Showing high-performing providers at the top of "find a provider" listings to drive more patients/members to them, increasing patient volume while elevating the overall level of care.
  • Providing them with badges indicating their preferred status which can be added to their websites, plaques or certificates that can be displayed on their walls, and listing them on the payer's/MCO's/TPA's website for that Medicaid program.

Reduce internal administrative costs
Technology-enabled solutions accessed through a dental or vision care hub can also have a profound effect on the administrative costs of payers, MCOs, and TPAs by:
  • Eliminating the costs to process paper claims as well as print and mail paper checks and remittance documents.
  • Reducing the top two reasons for provider call volumes: inquiries about patient eligibility and benefit coverage, and questions about the current status of clinical reviews and claims payments.
  • Making complete, accurate provider data (which is maintained by the providers themselves rather than payers/MCOs/TPAs) available instantly, ensuring accurate claims payments and benefit administration that drives down costs while reducing call volumes and increasing provider satisfaction.
  • Encouraging the use of text messages to monitor patient quality of care and potential fraud rather then ineffective traditional methods such as mail surveys, which often fail to reach their targets. Today, cell phones are rarely used by health plans who want to communicate with Medicaid members.
  • Creating revenue cycle dashboards that offer analysis of dental provider treatment patterns to reduce the risk of fraud, waste, and abuse, resulting in lower benefit costs and improved patient health outcomes.
  • Complying with regulatory requirements for provider data verification and credentialing through centralized databases that can be accessed on-demand.
Reducing benefit management costs
A third area where technology-enabled solutions can help is in lowering the cost of the actual benefits, making more money available for care. For example, through big data analytics powered by artificial intelligence (AI), payers, MCOs, and TPAs can identify high-performing dental and vision providers in their networks so they can help drive more members to them. They can then redesign reimbursement schedules to direct more money to high performers, creating an incentive for more providers to improve their care quality.

Big data analytics can also be used to perform an in-depth analysis of how Medicaid benefit dollars are being spent in each market to help optimize how the money is being used. An analysis might determine that reallocating Medicaid dental and vision dollars to promote and expand the use of preventive services will reduce the need for (and spend on) more expensive procedures in the future. It can also help determine which services should be included as part of a standard benefit offering based on what is already available in specific markets.

This same technology can be used to analyze reimbursement schedules and methodologies at the provider and program levels to ensure limited dollars are being spent in the most efficient and effective manner.

Expansion doesn't have to mean expensive
The prospect of Medicaid expansion reaching into more states is generally viewed as a good thing. But it brings some challenges with it.

In terms of patient value, Medicaid delivers to its beneficiaries what could be called a "monthly miracle" when compared to the cost of commercial healthcare benefits. A state today might pay as little as $225 per person monthly for individual care that would otherwise cost four times that amount. That would be if you could even find a health plan offering first dollar coverage with no out-of-pocket patient expenses including prescription drugs, dental and vision. Good luck with that.

By taking advantage of technology-enabled solutions now, states (and the payers, MCOs, and TPAs who serve them) can ensure they can not only meet the future demand but deliver even greater programs and service to the most vulnerable among us.

Craig Kasten is chairman and co-founder of SKYGEN USA, a company that is powering healthcare transformation forward through innovative, next-generation technology-enabled solutions and data analytics that inspire stakeholders to challenge the status quo and create better alignment to drive efficiency, reduce costs, and elevate experiences for all throughout the digital age. Craig can be reached at

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