DOH Continues APG Carve-Out

Published on: March 15th, 2011

From: New York State Dental Journal

The New York State Department of Health (DOH) is implementing a new methodology for Medicaid payments to Article 28 facilities. This new methodology, Ambulatory Patient Groups, or APGs, replaces the previous rate-based reimbursement methodology.

Last March, DOH announced that physicians were temporarily “carved out” of the payments made to Article 28’s. The Health Department would reimburse facilities based on the APG methodology and would also reimburse physicians who bill for professional services based on the existing Medicaid fee schedule. However, dentists who treat ambulatory patients in Article 28 facilities could no longer submit claims to DOH for Medicaid reimbursement. The department intended that professional services provided by dentists be included in the APG dental reimbursement rate to the hospital. Using the APG methodology, DOH could reimburse Article 28 facilities with one payment for each Medicaid medical or dental visit and the institution would reimburse the doctors directly.

NYSDA contacted DOH with its concerns about the impact the new methodology would have on access for patients with special treatment needs. NYSDA pointed out that most dentists do not have employment relationships with the Article 28 facilities in which they practice. As a result of the change in reimbursement, Article 28 facilities began discontinuing care for pediatric patients and those with disabilities and special medical needs who require dental treatment in operating room. This past October, DOH excluded dentists from the APG methodology, allowing both dentists and physicians to continue submitting claims to Medicaid.

In November, DOH responded to NYSDA’s continuing concerns about access under the following policy provisions:

DOH is extending dental fee schedule billing in the OR setting at the current levels until April 1, 2011.
Beginning on April 1, dentists will continue to be able to bill directly against the fee schedule for services in the OR at a reduced rate—equivalent to 65% of the current payment. According to DOH, this new payment is “designed to be the ‘professional only’ expense for delivering facility-based service in the OR.”
DOH increased the payment for dental anesthesia significantly (to about $540 on a statewide average) beginning on Jan. 1. This additional payment will go to the hospitals and is intended to “help to better align payment to actual cost and will incentivize access to the service.” According to DOH, “hospitals have, in many cases, neglected to bill for the anesthesia using the applicable ‘D’ codes so they need to know that they can and should use those codes and that those codes will now pay a greatly enhanced rate.”
Finally, on April 1, DOH will either create a new, higher ambulatory surgery dental APG base rate or further enhance the payment for dental anesthesia.

H announced its planned changes through the hospital associations and asked that NYSDA help inform dentists of changes to the Medicaid protocols. NYSDA has responded to DOH, pointing out continued concerns about the impact these changes will have on access to care because of the reduction in reimbursement these policy changes represent.

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