Prairie State Wire

Illinois Department of Healthcare and Family Services Dental Policy Review Committee met Feb. 29.

Here are the minutes provided by the committee:

Dental Policy Review Committee Member Present

Dr. Jason Grinter, Chair, Delta Dental, Onsite Dental

Dr. Danny Hanna, University of Illinois Chicago

Dr. Flavia Lamberghini, University of Illinois Chicago/Apple Dental Care Lindsay Wagahoff, ISDS

HFS

Aimee Isham, BPAS, Hospital

Jose Jimenez, BPAS, Bureau Chief

Dorian Manion, Director’s Office

Dani Mendez, Legislation Liaison

Amy Moffat, BPAS, Non-Institutional Provider

Kelly Pulliam, BPAS, Dental

Bradley Ray, BPAS, Dental

Other Interested Parties

Dr. Chelsea Fosse, AAPD (American Academy of Pediatric Dentistry)

CALL TO ORDER AND INTRODUCTIONS

Dr. Jason Grinter called the meeting to order at 10:00 a.m. Dr. Grinter turned the meeting over to HFS to address follow up from the February 29, 2024 Subcommittee Meeting.

Jose introduced Amy Isham and Amy Moffat. He then explained that HFS included departments such as Hospitals, NIPS, the Director’s Office, Legislation, and Dental on the call so that we can address the concerns of anesthesia as a group. Kelly Pulliam stated that Dr. Hanna originally brought forth the concerns at the January DPRC meeting and turned the discussion over to him.

HOSPITAL ANESTHESIA FOR DENTAL CASES:

Dr. Hanna explained that the purpose of the discussion is to address the low reimbursement for hospitals during dental procedures. He stated that a new code was introduced on the Medicare side and states are being encouraged to implement. He stated that hospitals are not getting the proper reimbursement for these cases, so operating room time for dental procedures has quickly declined. He then turned it over to Dr. Fosse for a more thorough explanation.

Dr. Fosse agreed with Dr. Hanna’s statements and continued by saying that CMS recognized the need for dental OR time and acknowledged that the hospital dental OR times have been slashed. Studies have shown that hospitals are currently receiving a $200 facility fee for dental cases. She explained that this is extremely low, and that

CMS would like to utilize the 41899 code or the G0330 code. Dr. Fosse mentioned that three other states; Colorado, Washington, and Florida, are currently implementing work arounds. However, she explained that this is just for the facility fee.

Dr. Grinter then stated that he has been doing dental OR cases for the past 20 years and he understands the low reimbursement. Hospitals in Stephenson and LaSalle counties have turned down his cases.

Dr. Fosse stated that CMS originally assigned a $1,722 fee; however, has since changed it to $3000.

Dr. Lamberghini agreed.

Jose then explained the State of Illinois Hospital EAPG (Grouper). He explained that each hospital receives a different reimbursement, and each case receives a different reimbursement based on calculations thru the grouper. He gave an example of a hospital case that billed the State of Illinois for $5 million; however, they were reimbursed $2.2 million due to the grouper.

Aimee Isham then stated that HFS does not pay facility fees.

Amy Moffat explained that if anesthesia is not covered in the hospital’s cost report, then a professional claim could be submitted for the anesthesiologist, and reimbursement utilizing the anesthesia formula would apply. Each case uses a formula with time spent, modifier applicable the patient’s physical status (“physical status modifier”), and a conversion factor; therefore, each surgery pays a different rate. She mentioned that the 41899 is a covered code on the NIPS side.

Aimee Isham asked what would happen if not performed in a hospital setting.

Dr. Lamberghini said that these cases are still being completed, but in a dental office setting.

Dr. Hanna stated that there are two different issues: hospital reimbursement and medical anesthesiologist billing.

Jose explained that the grouper is not flexible and it’s very complicated. Dr. Fosse stated that wait times for these cases are sometimes 2-3 years. Lindsay from the ISDS asked if HFS is willing to do single case agreements.

Jose stated that MCO’s have more flexibility; however, due to the State Plan, FFS cannot. Jose also mentioned that rates have been increased in the past 3 years; however, with low participation from dental providers, it creates access to care issues.

Jose mentioned that only 1/3 of licensed dentists in Illinois accept Medicaid and he’d like to see this increase.

Dr. Grinter mentioned that there are approximately 20 dental providers in the entire State of Illinois that perform care in a hospital setting; and there are very few hospitals that take these cases.

Jose stated that he has an upcoming meeting with the Illinois Hospital Association, and he will add this topic to the agenda.

Dr. Grinter stated that he’d like to have a further discussion about medical anesthesiologist billing.

The committee agreed to 2 additional 30-minute subcommittee meetings; 1. Follow up from the IHA meeting. 2. Further discussion surrounding medical anesthesiologist billing.

ADJOURNMENT

Dr. Grinter stated that he would send out invites. The meeting adjourned at 3:00 p.m.

https://hfs.illinois.gov/content/dam/soi/en/web/hfs/sitecollectiondocuments/02292024dentalanesthisasubcommitteemeetingminutes.pdf