Eleven practices are urging a judge in a Manhattan federal court to prohibit an insurance middleman from changing how they get paid for Medicare and Medicaid patients.
DentaQuest, a third-party insurance provider based in Massachusetts, threatened to switch the practices’ payment model by April 1, a move the practices say could shutter some of them and erode dental care for more than 100,000 patients, according to a request for a temporary restraining order filed by the clinics. U.S. District Judge Mary Kay Vyskocil granted the clinics’ request to delay the reimbursement change on Wednesday, pushing off the move until the court holds a hearing on April 8.
But if those changes come to fruition they could still be detrimental for the clinics, they say. If DentaQuest adjusts their rates, the practices will be “excluded from the networks of virtually every New York state health plan for no valid reason and the majority of the practices will be immediately closed,” the legal filing said.
Shuttering dental practices that accept low-income patients could exacerbate existing barriers to dental care, the practices say. One in six New Yorkers who needed dental care in the past year could not get it, in part because of the small number of practices that accept Medicaid, according to a survey released last year by SUNY Albany’s Center for Healthcare Workforce Studies.
A representative from DentaQuest did not respond to a request for comment by publication.
DentaQuest, an independent physician association, contracts with Medicare and Medicaid plans to coordinate oral care for their members. The eleven practices that filed the lawsuit against DentaQuest are in-network for health plans, including HealthFirst and Affinity, and DentaQuest refers patients to those clinics to receive services, legal filings say.
Last year, DentaQuest informed the practices that it would be shifting its payment model for HealthFirst and Affinity patients to “fee-for-service,” meaning that the clinics would receive reimbursements for every individual service provided, according to the filings. The practices were previously reimbursed through a capitation model, receiving a monthly cash payment upfront for every health plan member, regardless of what services were rendered. The shift to a fee-for-service model – which the clinics say is a breach of their contract that extends through 2026 – would effectively cut their reimbursement rates and make it impossible to keep their doors open.
The practices are ultimately seeking to block the change. In the meantime, some have sent letters to patients informing them that they should seek alternative options for care. 42nd Street Dental Associates PC, a clinic based in Midtown, sent notices to patients informing them that they would close down on April 30, according to a copy of the letter reviewed by Crain’s.
