Even though officials and some practitioners say the NCTracks system has improved, there are still providers who struggle with the new computer system.
By Rose Hoban
More than seven months after the rollout of a new Medicaid billing and claims tracking system, dentists who provide care for low-income patients continue to struggle with payment for their work.
Chapel Hill-based dentist Larry Moray reports that his orthodontics practice is more than a half-million dollars behind as a result of problems with NCTracks.
“We have seen about a 50 percent decrease in our Medicaid receipts since going live with NCTracks,” Moray said. “That’s even as our production has gone up.”
Moray is one of many health care providers who need to get paid for services delivered. Leaders in the state Department of Health and Human Services’ Division of Medical Assistance, the section of state government that manages Medicaid, recently told lawmakers that there are between $80 million and $120 million in unpaid claims as a result of issues with NCTracks.
Moray’s orthodontics practice is large: He has 11 offices housing about 50 orthodontics chairs and about 30 general-dentistry chairs in the Triangle and eastern part of the state.
And he does a lot of Medicaid work.
Moray’s cheerful Chapel Hill office boasts five chairs in a row in one room and several private rooms. He said his practice is pretty efficient.
“If you are extremely efficient and you see a boatload of patients,” you can make Medicaid orthodontics work, Moray said. It’s tougher to make money doing Medicaid dentistry because of the higher overhead for general dentistry, he said.
“I used to be part-time faculty at [the UNC School of Dentistry], and students used come up to me all the time and say we always heard you can’t make money doing Medicaid dentistry. And I would say, ‘That’s not true,’” Moray said.
“I would show them our profit-and-loss statements, and it would be, like, here is how much it costs us to run the office, here is how much we pay the dentist, there’s what’s left over at the end of the day.”
Moray said that before the launch of NCTracks, his 11 offices were pulling in between $150,000 and $200,000 in Medicaid receipts per week. But that number’s fallen by about half since last July, to between $80,000 and $90,000 per week.
The reduction in payment has put Moray about $350,000 behind in receipts and several of his vendors have threatened to take collections action against him.
“Invisalign and Procter & Gamble both have frozen our account; we get calls from them daily,” Moray said during a Feb. 14 interview. “The bank has informed me that I’m in violation of our loan covenants because our balance is so low.”
He’s had some good news this week, in the form of an agreement from North Carolina Medicaid to get an emergency advance on his Medicaid payments.
But other dentists contacted for this story said they’re fed up. Several, who declined to be quoted, said they were planning to do fewer Medicaid cases in the future.
Health departments frustrated
The problems with reimbursement are not limited to orthodontic practices like Moray’s. Christy Bradsher, financial administrator at the Orange County Health Department, said their clinic has been seeing Medicaid dental patients all year; but by the end of January, they’d only received about $3,000 in reimbursement for their work.
“With NCTracks, we’ve met only 1.7 percent of our projected Medicaid dental revenue as of the end of January,” she said.
Bradsher said the Orange County Board of Health has been understanding of the lag in revenue.
“Being a county government, our budget is set for the fiscal year; so it buys us more time than a private office. So we literally have until the end of the fiscal year [in June] to bring in the money,” she said.
“Normally at this time of the year, we’re [exactly] on the amount we forecasted; but we’re not, and the clock is ticking,” Bradsher said. “We’re getting anxious about whether they’ll fix all the problems they’re having.”
She said that at the beginning of February, her department did receive an additional $30,000, but that that’s just a fraction of what they’re owed.
Lynnette Tolson from the N.C. Alliance of Public Health Agencies said several local health directors have been raising issues with NCTracks.
“State Health Director [Robin] Cummings was getting health departments their money even before he was made the head of the Division of Medical Assistance,” which runs Medicaid, said Tolson, who noted that many health departments are still behind in their receipts from NCTracks. “Those departments can’t keep hanging on without it.”
Michelle Herd, a spokeswoman for Computer Sciences Corporation (CSC), which the state hired to set up NCTracks, wrote in response to an inquiry from NC Health News that many of the people submitting claims are making common mistakes in entering medical code for billing. She said that some of those mistakes are because the Affordable Care Act mandated edits in the coding, edits that providers are not familiar with yet.
Herd also said the system is kicking back many claims that should not be covered.
“CSC is committed to the success of NCTracks for Medicaid recipients and the providers who use the system,” Herd wrote.
“As of February 11, 2014, NCTracks has processed more than 120 million claims and paid more than $6.4 billion to North Carolina healthcare providers, and the system is working for the great majority of NCTracks users.”
Not every kid on Medicaid gets braces, only those who have teeth that are dangerously “occluded,” crowded together, or whose jaws are misaligned.
“You have to have a pretty severe crowding, bite issues …” said Moray, who noted that only kids with “moderate to severe” cases get covered for orthodontia.
“Some of this stuff is pretty straightforward. But the Medicaid population is so complicated that if you finish a case in 24 months, you’re doing pretty good. A lot of our cases run for two to three years because they are so severe.”
Moray’s office manager, Lyndsay Luca, said that in the past they would take all the records from a case, the X-rays and the mold made of the child’s mouth and send it off to Medicaid to get reviewed and approved for orthodontic work.
“It used to take two weeks,” Luca said. “They would put everything back in the box, the letter approval or denial, and then we would call the patient and tell them.”
But since the arrival of NCTracks, some of that has changed. The system supports sending all of the records and X-rays electronically, but Luca still has to send along the molds.
“It was taking four to six weeks to get approvals back, and then they lost the doctors doing the approvals,” she said.
That’s another source of Moray’s losses: the shortage of orthodontists to review cases and give prior authorization to Medicaid cases.
Moray used to be one of the orthodontists who reviewed cases for Medicaid.
“They would pay on a per-case basis,” he said. “You would go in, pick up a tub of files, go home and go over them after dinner, when the kids went to bed, and then bring them back.”
But since the digitization of the system, that’s no longer possible. Now consultants have to go to the office in Raleigh to review the cases during business hours.
“They pay an hourly rate, which is about what you would get paid as a massage therapist,” Moray said. “Most of these orthodontists are saying that I could make a lot more for that hour. I’m not being paid for my time.”
That’s led to a huge backlog in prior authorizations for care. Moray estimates he’s got about $300,000 worth of work on hold because he can’t get authorization.
“We have parents calling us, wondering, ‘Where’s the braces? Why can’t you put them on?’” Moray said.
“It’s really a huge disservice to the patients not to be getting stuff done in a timely fashion,” he said, “in addition to the fact that it’s totally hamstringing every orthodontist who accepts Medicaid in the state.”
Moray has been helping DHHS find orthodontists to review cases, but many can only give an hour or two to the effort. Meanwhile, the cases back up.
A DHHS spokeswoman admitted to the backlog in prior authorizations, but she also said that for the week of Feb. 7, 88.5 percent of dental claims were paid.
According to Herd, the CSC spokeswoman, “We continue to work through the requests for prior approvals and expect to reach targeted inventory levels by the end of March.”