Rule Change Could Improve Access To Dental Care For People With Disabilities

Dr. Marc Rosenthal, center, performs oral surgery on Andy Mitchell, a young man with intellectual and physical disabilities, at St. Bernard Hospital’s dental clinic in Chicago in 2018. (Antonio Perez/Chicago Tribune/TNS)

Dentists say bureaucratic issues are forcing children and adults with disabilities across the nation to unnecessarily wait six to 12 months for care, but a fix could soon be on the way.

Three leading dental groups wrote to the Centers for Medicare & Medicaid Services earlier this summer citing “significant concerns” about access to dental procedures in hospitals and similar settings.

“The lack of (operating room) access for needed and covered dental procedures often results in wait times of 6-12 months for these patients, many of whom are children whose daily activities and school performance are often significantly affected in the interim,” wrote officials from the American Academy of Pediatric Dentistry, the American Dental Association and the American Association of Oral and Maxillofacial Surgeons.

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“We attribute most of this access challenge to the lack of a sustainable billing mechanism for hospitals and (ambulatory surgical centers) to report dental surgical services in both Medicare and Medicaid,” the groups indicated.

Specifically, they said that with the existing billing code that hospitals use for dental patients who require operating room access, Medicare provides a rate of just $203.64, far short of the $2,334.87 average cost for such services. As a result, the dental groups contend that hospitals are reluctant to schedule their surgical cases.

Meanwhile, current Medicare regulations do not allow for coverage of dental surgeries at ambulatory surgical centers, which dentists say could help to alleviate pressures stemming from the lack of access to hospital operating rooms.

The impact is widespread, the letter notes, since Medicaid programs often model Medicare rates and both Medicaid and commercial insurance typically follow Medicare’s lead to determine what to cover.

“Limitations in access have been exacerbated by the COVID-19 pandemic, primarily affecting high-risk Medicaid and commercially insured patients who, due to their particular medical conditions and other circumstances, require an operating room (OR) setting for the performance of extensive dental procedures,” the groups wrote to CMS.

Similar concerns have been raised by the Consortium for Citizens with Disabilities Health Care Task Force, the American Academy of Pediatrics and members of Congress.

Now, CMS is working to make changes. Under a new proposal, the agency plans to update the Medicare code that hospitals use to bill for dental procedures in operating rooms. The new code would allow for a payment rate of $1,958.92.

Dr. Jane Grover, senior director of the Council on Advocacy for Access and Prevention at the American Dental Association, said that if approved the CMS proposal “would take a significant first step forward toward improving access to needed dental surgeries for children and adults with disabilities.”

In addition, Grover indicated that “the dental community is continuing to advocate for reforms that would help to ensure there is sufficient operating room capacity to support dental surgical access for disabled patients served by Medicare and Medicaid.”

The proposed rule is up for public comment through Sept. 13. If finalized, the changes would take effect Jan. 1.

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