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El Paso Medicaid Patients Pay to Continue Treatment

Tens of thousands of orthodontia patients with dental work once paid by Medicaid, but cut off from treatment when their orthodontists came under investigation, have been abandoned by their orthodontists; a situation that drew Texas Medicaid stakeholders to a meeting in Austin on Friday, to decide what to do about it.

Some orthodontia clinics discontinued treatment for their Medicaid patients after Texas Medicaid stopped payment for claims made by certain clinics being investigated for fraud.

The Texas Health and Human Services Commission (HHSC), dentists and managed care directors discussed the future of Medicaid patients who have been dismissed by their orthodontists during their course of treatment.

HHSC had decided that Medicaid will continue to pay for treatment of patients with six months or less left in their treatment plans.

All other cases will have to be resubmitted and reevaluated to determine whether or not the claims were medically necessary when they began.

If evaluators find the cases did not meet Medicaid’s criteria as being medically necessary when the braces were put in place, state officials say Medicaid will pay to have the braces removed.

A stumbling block for Medicaid patients is that many are having a hard time finding orthodontists willing to take their transfer cases.

Orthodontists willing to accept the patients are being overwhelmed by what state officials call thousands of abandoned patients.

In some instances, former patients were so desperate for treatment, they returned to the orthodontists who had dismissed them, now as private-pay clients.

Sun Orthodontix, with four locations in El Paso, is one of the clinics under investigation where state officials say there is credible evidence of fraud.

In 2009 and 2010, National Orthodontix Management, the parent company of Sun Orthodontix, was the highest biller of Texas Medicaid Orthodontics.

“What’s the point of getting braces if they’re not doing anything?” said former Sun Orthodontix patient Courtney Lambert.

Lambert was hoping she would have her orthodontia treatment completed by the time she graduated from high school.

She received her diploma in June but still has braces on her teeth. “My last visit, I was supposed to get my bottom wire,” Lambert said. “They showed my mom a paper saying that they weren’t seeing anymore people with Medicaid, and that if we want to continue seeing them, we have to make a payment plan.”

ABC-7 has obtained new contracts between Sun Orthodontix and its former Medicaid patients.

The new contracts are requiring patients to make payments on the orthodontia treatment formerly paid for by Medicaid.

HHSC spokeswoman Amy Goodman says it is illegal for a Medicaid-providing orthodontist to request payment for treatment from Medicaid clients.

Even though the clinics may no longer be allowed to accept payment from Medicaid, they are still not adhering to the “spirit of the law,” Goodman says.

One father tells ABC-7 he had to return to Sun Orthodontics because his daughter’s brackets from her braces were coming off of her teeth.

He says in order for Sun Orthodontix to cement the brackets back onto his daughter’s teeth, he would have to sign a contract for the duration of his daughter’s treatment.

When he said could not afford the treatment, he says he was guided to a financing office in the back of the Sun Orthodontix clinic.

He says it was then that a Sun Orthodontix employee got a bank on the phone to assist the man with getting a loan.

The loan was secured for the completion of his daughter’s treatment, with an interest rate of 15 percent.

State officials are asking that patients contact their managed care organization rather than sign private-pay contracts with the orthodontia clinics that dismissed them.

On Friday, Dallas-based All Smiles Dental Centers announced it would be closing all of its locations.

All Smiles is another chain of dental clinics under investigation by the state for fraud.

The clinics had been dismissing patients after Medicaid cut off payment to them amid the fraud investigation.

A spokesman for All Smiles says about 12,000 patients will be dismissed from the clinics.

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