Loophole allows some adult dental Medicaid claims

An obscure federal law is allowing California dentists to get reimbursed by Medicaid for treating adults -- even though the state officially terminated adult benefits. And federal officials say the law could apply in other states as well.

The Federally Required Adult Dental Services (FRADS) law provides that if a state Medicaid program will reimburse a physician for any sort of dentistry, it has to reimburse a dentist for the same procedures. In California, physicians can be reimbursed for extractions and even sedative fillings.

"If a physician can do it, you've got to pay the dentist to do it," said David Noel, D.D.S., M.P.H., chief dental program consultant for the California Medicaid program.

The law has come into play in California because the state on July 1 terminated what was once the most comprehensive package of adult dental Medicaid benefits in the U.S. Some states have taken similar action, others still are considering it, and many never provided such benefits to begin with.

La Clinica de la Raza, in Oakland, CA, makes use of FRADS daily to get reimbursement for patients who might otherwise not get care, said Ariane Terlet, D.D.S., the clinic's dental director. "As much as we can bill under these services, we do," she said.

She points out, however, that FRADS provides only a bare minimum in California. It will pay for re-cementing crowns, inlays, and onlays; for local anesthesia and anxiolysis, including nitrous oxide; and for many types of oral surgery, in addition to extractions and sedative fillings. (California will also pay for some dentistry for pregnant women and nursing home patients.)

Not just emergency care

In some cases, physicians are allowed to do these procedures so they can help patients with traumatic injuries. But dentists can do important work with even these few procedures, said Dr. Noel. "There's nothing that says it has to be an emergency service."

For example, sedative fillings are often used in developing countries -- where they are called atraumatic restorative treatment -- as a low-cost alternative to complete restorations. He has heard of some such temporary fillings, which have also been used in the U.S. military, lasting 20 years.

But the law can't be applied in every state. "There is a sort of caveat," said Conan Davis, D.M.D., M.P.H., chief dental officer for the U.S. Centers for Medicare & Medicaid Services. "The state has to license the physician to do these procedures."

No one has kept track of how many state Medicaid programs reimburse physicians for dental work. And some clearly do not.

Medical doctors can't get reimbursed for pulling teeth or sedative fillings under Medicaid in Alabama, said Robin Rawls, spokesperson for the program there. "We're familiar with the (law), but we don't provide adult dental benefits. We just don't have the money."

Asked what would happen if a patient showed up in an emergency room with broken teeth from a car accident, she said, "I can't speculate on this situation or that situation."

Dr. Noel has assembled a list of the procedures for which California will reimburse dentists who care for adults under the Code on Dental Procedures and Nomenclature.

Dentists in other states should contact their state Medicaid office individually, said Dr. Davis.