Medicaid Audit Intelligence

Evidence record

Medicaid Dental Benefit Program Manager - DentaQuest Informational Brief

Jurisdiction
Louisiana
Publishing agency
Louisiana Legislative Auditor
Publication date
July 31, 2024
Source record
Original document linked
Open original reportOriginal source available

Findings

10

Recommendations

0

No formal recommendations were issued in this record.

Overall conclusion

The informational brief presents a comprehensive analysis of DentaQuest’s performance as the Medicaid dental benefit program manager, highlighting ongoing concerns with network adequacy, claims processing and denials, provider credentialing, and contract compliance, while noting improvements in certain financial metrics and ongoing management responses; the findings inform legislative oversight and potential policy actions related to provider networks, penalties, and program administration.

Scope

This informational brief analyzes the Louisiana Department of Health’s Medicaid dental benefit program management by DentaQuest (and MCNA as the other program manager) from January 1, 2021 through March 31, 2024 for PMPM payments and provider service data, with broader context through the end of March 2024; it covers payments to DentaQuest for dental coverage to approximately 1.2 million unique Medicaid members, total services paid (approx. $232.7 million) and PMPM totals ($408.0 million) for the period; it assesses the adequacy of the provider network, including the number of contracted providers by specialty, geographic distribution across Louisiana parishes, and whether network capacity meets member demand; it reviews provider complaints and formal claims disputes, member grievances and appeals, and noncompliance with contractual requirements; it notes that LDH contract with DentaQuest requires at least two DBPMs to offer member choice and discusses changes in policy such as the 2022 adult expansion and 2023 to 2024 FMP changes; it includes analysis of penalties assessed for noncompliance through June 2024 and the LDH external quality review process; it relies on DentaQuest and LDH contract deliverables and Medicaid data and relies on non-independent verification of all underlying data.

Findings (10)

Each finding has a stable link.

  1. F-446

    LDH paid approximately $408.0 million in per-member-per-month payments (PMPMs) to DentaQuest for dental coverage of about 1.2 million unique Medicaid members from January 1, 2021, through March 31, 2024; DentaQuest provided approximately $232.7 million in dental services in the same period, with Full Medicaid Pricing (FMP) payments totaling $80.5 million included in PMPMs, resulting in about $313.2 million paid to DentaQuest’s dental providers.

  2. F-447

    DentaQuest did not meet the contract requirement to spend at least 85.0% of PMPMs on dental benefits and services for calendar years 2021 and 2022, leading to a refund of approximately $9.1 million; MLR reports showed improvement from 2021 to 2022.

  3. F-453

    LDH issued penalties totaling over $2.059 million to DentaQuest for noncompliance between Jan 2021 and Jun 2024, with the largest share of penalties tied to claims and encounter management and to provider network issues; penalties were assessed in two periods (Jan 2021–Aug 2023: $1,124,500; Sep 2023–Jun 2024: $935,000).

  4. F-448

    FMP payments to the DBPMs were discontinued in July 2023, with LDH increasing fee schedule rates instead.

  5. F-449

    DentaQuest did not meet all network adequacy requirements as of June 2023 or June 2024, with broad provider shortages across the state; many parishes had no general dentists or no specialty providers, and total contracted providers declined (General Dentist 801 to 693, Pediatric Dentist 86 to 74, Endodontist 10 to 5, Periodontist 5 to 3, Prosthodontist 23 to 3, Orthodontist 19 to 14, Oral and Maxillofacial Surgeon 33 to 24).

  6. F-450

    As of June 2024, DentaQuest reported no dental providers in five parishes for general dentistry and 40 parishes without any specialty providers; distance requirements were not met in several parishes for multiple specialties, even after LDH lowered the distance threshold from 90 miles to 75 miles in July 2023.

  7. F-451

    DentaQuest experienced a large volume of provider complaints related to claims processing, with 896 complaints in calendar year 2021; 23 complaints (Jan-Jul 2023) and 24 complaints (Aug 2023–May 2024).

  8. F-452

    Grievances and appeals indicate ongoing member dissatisfaction with quality of care and denial/limited authorization of services; between Jan 2021 and Jun 2023, 1,847 appeals occurred (with 43.9% resolved in favor of the member), and between Oct 2023 and May 2024, 329 appeals occurred (35.0% resolved in favor of the member).

  9. F-454

    DentaQuest’s credentialing delays and communications issues were recurring concerns cited by providers; some credentialing delays extended six to twelve months, and some applications were reportedly lost.

  10. F-455

    LDH does not independently validate underlying claims data used by DentaQuest; external QA reviews are used.

Recommendations (0)

This record contains no formal recommendations.