Quarterly Payments for Orthodontic Services (APA WF # 23-21)
The Oklahoma Health Care Authority (OHCA) proposes to transition the current orthodontic payment protocol from a bulk payment system to a quarterly payment protocol. The new payment protocol will be based on twenty-four (24) months with built in progress reports. Proposed revisions will remove outdated language and add new language to delineate the new payment criteria and billing instructions.
Please view the draft circulation documents here: APA WF # 23-21 and submit feedback via the comment box.
15-day Tribal Consultation Period: 10/27/2023 – 11/11/2023
Tribal Consultation: 10/31/2023
Circulation Date: 10/27/2023
Comment Due Date: 11/10/2023
Submit a Comment
After you submit your comment, you should be re-directed to a confirmation page. If you are not, please submit your comment through e-mail to federal.authorities@okhca.org.
Please note that all comments must be reviewed and approved prior to posting. Approved comments will be posted Monday through Friday between the hours of 7:30 a.m. – 4 p.m. Any comments received after 4 p.m. will be posted on the following business day.
Comments
Priscilla
No issues with the changes in submission or the switch to quarterly payments, but expecting orthodontists to take an even bigger financial hit by not allowing reimbursement after two years of treatment is extremely problematic. Only the most challenging orthodontic cases are approved, and it is unrealistic to think surgical cases and cases with impacted canines, etc., can be completed in 24 months. Reimbursement rates are already extremely low for two years of comprehensive orthodontic treatment. Access to care is already problematic for many patients, and I believe this will become substantially worse if many offices have to stop accepting new patients with this insurance, as we will need to do (for financial reasons), if this goes through.
OHCA Response:
Thank you for your comment. To clarify, the new payment protocol will keep the same total payment amount as the existing bulk payment system. The total payout will be disbursed in 24-months as opposed to the previous 36-month period, with the intended effect of promoting better tracking of care for transfer cases when needed. The total reimbursement remains the same, however it will be paid over a shorter time span. Currently, the total payment is done over a period of 36 months, but if treatment is completed in 23 months for example, the provider does not receive any payment for the third year. This new payment protocol will ensure the provider receives payment for the full treatment within 24 months regardless of treatment duration. See below for example payment methodology:
Comprehensive Orthodontic treatment is currently paid in this format:
1st year - $1638.03
2nd year - $905.25
3rd year if medically necessary - $905.25 Total = $3448.53
New payment structure would combine all 3 years of payments to be paid out in 24 months:
1st 12 months - $1638.03
Subsequent payments:
Quarter 1 - $452.63
Quarter 2 - $452.63
Quarter 3 - $452.62
Quarter 4 - 452.62
Total = $3448.53
