LITTLE ROCK — A North Little Rock oral surgeon who was paid $100 per hour to be a Medicaid watchdog said he doesn’t remember rejecting a single claim out of the tens of thousands he reviewed over the past decade. And in an interview, he said he won’t deny any claims in the future if he is asked to review them.
As an oral surgeon, Dr. Robert Jolly Jr. relies on referrals from dentists. As an oral-surgery consultant assisting the Arkansas Department of Human Services, Jolly was tasked with evaluating dentists’ claims and either approving them - fully or partially - or denying them.
From July 2008 through April 2011, for example, Jolly was paid $100 an hour to review claims. He collected $17,030 during that period, according to the department.
A department official said Friday that her agency was unaware, before being contacted by the Democrat-Gazette, that Jolly was unwilling to reject claims.
“We didn’t hire him thinking he was going to say ‘yes’ to all of them. That was not our expectation,” said department spokesman Amy Webb.
In part because of complaints of abuse in the Medicaid dentistry program, the Department of Human Services will retool its oversight system for dentistry claims after a longtime consultant criticized the agency and the state dental association.
It will take several months to create a new process and details are still being worked out, Webb said.
Robert de Bin, a Little Rock pediatric dentist who worked as a consultant for about 30 years, says the current system lacks proper oversight and is rife with conflicts of interest, abuse and fraud.
The policy change, announced Tuesday, comes after a two-month Arkansas Democrat-Gazette investigation into the system that found that Jolly reviewed about 40,000 oral-surgery claims since Jan. 1, 2009, without denying a single claim.
“There’s nothing to deny,” Jolly told the newspaper Tuesday.
Jolly said he didn’t want the “liability” of refusing a claim and risking a patient becoming ill or even dying from an infected tooth. “Think of the spot I’d be in. I have to assume a dentist has done what he needs to do to save the tooth.”
Jolly said the work didn’t pay as well as his oral-surgery practice and he did it only because no one else would.
“I’ve tried to quit for years and no one else would take that tar baby,” Jolly said, adding that he’d rather spend the time playing golf.
Jolly’s contract ran out Friday, but he says he will continue to serve as a “backup” for the agency.
Webb said department officials will meet with the Arkansas State Dental Association to discuss consultants’ contracts.
“We just want to make sure they understand explicitly what we want and what we expect in our reviewers,” Webb said.
If Jolly isn’t willing to reject any claims that he reviews, Human Services won’t use his services in the future, Webb added.
De Bin said Jolly’s failure to deny any of the 40,000 claims he reviewed since Jan. 1, 2009, is troubling.
“I’m shocked at that statistic. You don’t need a consultant if everything is approved. That’s a waste of $100 an hour. Just have somebody rubber-stamp it and forget it,” de Bin said.
De Bin said fraud and abuse are rampant in the Medicaid dental system. He said he resigned earlier this year, in part, because he was frustrated that no one was doing anything about it.
Eugene Gessow, the state’s Medicaid director, said de Bin’s complaints played only a minor role in the agency’s decision to make changes.
“Ninety-five percent of it” was due to an ongoing review process that sought ways to improve the system, Gessow said.
Gessow and Human Services Director John Selig questioned why de Bin hadn’t brought specific cases to their attention before speaking with the Democrat-Gazette.
Selig later said that de Bin had, in fact, lodged complaints with the agency in the past, but that state officials were unable to confirm their validity.
“They know what’s going on. But they never responded to anything I ever said,” de Bin said. He said he had raised his concerns about Jolly with department officials “for years.”
Having the dental association choose the consultants is a big conflict of interest, de Bin said. The association has a $150,000 annual contract with the state to provide the service and receives $6,000 for itself to cover administrative costs.
“One of the things that’s wrong with it, the fox is in charge of the henhouse. The [Medicaid] program isn’t being run for the benefit of the dentists; [the dental association’s] job is to make life easy for the dentist,” de Bin said. “The problem is within the system, allowing the tail to wag the dog.”
Before the dental association took over the contract, the review process was rundirectly by Human Services, which selected the consultants.
Webb, the department spokesman, said the state plans to change the prior-authorization model for at least some procedures. Where now a consultant such as Jolly examines claims before approving or denying them, the new system would initially approve many claims then subject some of them to a “retrospective ... evidence based” review, she said.
As a result, the role consultants play in approving claims will be lessened.
Already in place is a computer program that checks all claims and identifies “outliers” or questionable data, Gessow said.
The director said the state also has a hot line and investigators, but can’t check on every claim or each consultant.
“No medical system in the country could run like that,” he said.
Selig said the agency is eager to root out fraud and abuse, but relies in large part on dentists to coming forward.
“They have an ethical responsibility to do so,” Selig said.
The change in Jolly’s status and how the state will review Medicaid dental claims have been in the works for several weeks, Webb said, but the agency announced the policy shift at the end of June.
As recently as June 21, weeks after the Democrat-Gazette requested Jolly’s claim evaluations through the Freedom of Information Act, Webb said that Jolly would continue as a consultant for fiscal 2012, which started Friday.
Jolly later said he recently decided that he didn’t want the hassle of reviewing claims.
The decision to get rid of the current system was made about a month ago, Webb said, but she didn’t mention it during course of several interviews with the newspaper until de Bin went on the record with his criticism last week.
She said in the June 21 phone interview that the fact that Jolly hadn’t denied a claim in more than 2 1/2 years didn’t raise any concerns for the agency.
“Unlike some other things, in general, when there is a request for oral surgery, it’s necessary,” Webb said at the time.
Oral surgery isn’t a Medicaid service that has been of concern to Human Services for that reason, Selig said, adding that dentists can make more money saving a tooth than pulling it.
“It’s not very ripe for abuse,” he said.
Medicaid covers many poor and disabled adults and low-income children. De Bin says that many of the abuses involve dentists performing unnecessary procedures on children. When asked if children might be not be in the position to question the necessity of oral surgery, Webb suggested that the newspaper contact the parents and ask them.
Human Services, citing privacy laws, didn’t release any parents’ names, patient names or ages to the newspaper.
De Bin said he was hesitant to say anything, but thought it was his duty to protect taxpayers.
“I feel like I’m obligated to speak about this,” he said. “It’s my life and my career and I’m surrounded by people in the dental profession, and people who have abused the profession are friends of mine. It’s like they wear two hats. A lot of my peer group will not care for me. And that’s difficult.”
About 772,000 Arkansans are enrolled in Medicaid. All children and most adults are eligible for dental care under the state-run $4.5 billion program. Webb said that some dentists submitted multiple claims for a single patient - for example, if a patient needs three teeth removed, then three separate claims might be made. And just because a procedure was approved doesn’t mean it was ever performed, Webb said.
Billy Tarpley, the dental association’s executive director, said the association “stepped up” a decade ago to help the state overhaul a “cumbersome” process. He said the latest shift would also help streamline the process.
The association lines up the consultants, but doesn’t monitor their decisions on claims, Tarpley said.
“That hasn’t really been within our purview,” Tarpley said. “We make sure the bodies are there to get the work done.”
Tarpley, who is distantly related to Jolly, said Jolly’s performance is “completely subjective” and that no one had ever complained to his organization about Jolly’s decisions. “The proper way to address it would be to file a letter with the dental association, or submit it through the proper mechanism. It surprises me that we’re having this conversation,” Tarpley said.
The dental association, which lobbies at the Legislature on behalf of dentists, “is the profession,” said Tarpley, adding that at least 90 percent of dentists in the state are members.
The association is working with the state to implement a new system, hopefully one that will electronically evaluate claims. That way, Tarpley said, fraud or abuse can be detected by statistical measures.
Jolly said that - although he doesn’t think he’s ever denied a claim - he would sometimes modify a claim when appropriate. For instance, if a claim was to remove a fully impacted tooth and an X-ray revealed that it was only partially impacted, he would approve payment for just partial impaction.
X-rays don’t show every type of decay or pain-producing condition, Jolly said. And he said he told Tarpley when hired a decade ago that he wouldn’t question a dentist’s treatment plan.
“If the tooth was there, that’s what I was looking for,” he said.
Human Services officials said Jolly never told the department that he had never denied a claim and didn’t plan to do so.
But Jolly’s performance never raised any red flags, Gessow said. The main problem, he said, with dental claims under Medicaid is the volume has increased substantially since many more adults became eligible in 2009.
“There is no evidence - at this point - of fraud or abuse,” Webb said.
The new way - which should be in place in about a year - to evaluate oral-surgery claims should be an improvement, Webb said.
“We want to take the subjectivity out of it.”
Front Section, Pages 1 on 07/03/2011