By Duane Tinker – The Toothcop
Dental Compliance Consultant | Former Law Enforcement Investigator | Guardian of Ethical Dentistry
🦷 Change Is Coming—Are You Ready?
If you think Medicaid compliance is complicated now, buckle up. Because we’re entering a new era—one shaped by technology, regulation, and accountability.
I’m Duane Tinker—The Toothcop—and after years in the trenches of dental compliance, I can tell you: the future of Medicaid compliance is about being proactive, not reactive.
Let’s explore:
- What changes are already unfolding in Texas
- Federal-level trends reshaping compliance
- How dental providers can prepare for what’s next
-
Why ethical compliance = long-term success
🔎 Medicaid Compliance in 2025: Where We Stand Today
In Texas and across the U.S., Medicaid compliance currently centers on:
- Accurate documentation and billing
- Delegation of duties to properly licensed staff
- Credentialing with TMHP and MCOs
- Following managed care guidelines and fee schedules
- Adhering to HIPAA, anti-kickback, and False Claims Act requirements
Audits, clawbacks, and investigations have increased—especially around codes like D1351 (sealants), D4341 (SRP), and sedation services.
So where are we headed next?
🔮 Trend #1: Tech-Driven Oversight
AI and Analytics Are Already Watching
States and MCOs are leveraging data like never before. Artificial intelligence is scanning:
- Outlier procedure frequencies
- Inconsistent documentation
- Provider location activity (even GPS logs, because who goes to the Bahamas and leaves their phone at the office?)
📈 Expect more prepayment reviews and automated audits based on billing patterns.
What to Do:
- Run your own analytics (figure it out)
- Watch your frequency of high-risk codes
- Use compliance software that flags unusual activity
🔄 Trend #2: Continuous Credentialing and Revalidation
No more “set it and forget it.” Future compliance means:
- Ongoing credential checks
- Routine documentation reviews
- Real-time license tracking (I do this for my clients and it makes a HUGE difference for them)
Texas and many states are moving toward integrated systems that sync with licensure boards and the state Medicaid Administrator (TMHP).
What to Do:
- Set calendar reminders for credential deadlines (gosh dang good idea, I’m telling you)
- Keep documentation organized and cloud-accessible
- Confirm your status with each MCO every year (and when requested)
- Keep your NPI profile up to date, too!
🧠 Trend #3: Mandatory Compliance Training for All Staff
The future isn’t just about what the doctor knows—it’s about what the whole team knows. Expect:
- Annual mandatory training requirements
- Documented participation logs
- Real-world fraud scenario training modules
In some states, providers are already required to certify team training during revalidation (or annually in New York).
What to Do:
- Implement quarterly team trainings
- Keep sign-in sheets or LMS records
- Make fraud prevention part of onboarding
🧾 Trend #4: Documentation Will Make or Break You
Charts will need to be:
- Complete (no missing fields)
- Consistent (SOAP notes match claims)
- Contemporaneous (documented at the time of service)
The Office of Inspector General (OIG) and Medicaid Fraud Control Units (MFCUs) have increased scrutiny on chart audits.
What to Do:
- Audit 10% of your own charts every quarter
- Train providers to document what they see, say, and do
- Avoid template abuse—customize every note
💬 Trend #5: Patient and Whistleblower Empowerment
Patients and staff are increasingly educated on what fraud looks like. With stronger protections under the False Claims Act and anti-retaliation laws, expect more:
- Qui tam lawsuits (private person suits ‘on behalf of the government’)
- Anonymous reports from former employees (they often know your dirty little secrets)
- Social media exposure (people are going to talk about you; control what people say about you by your actions)
What to Do:
- Foster a “speak up” culture in your office
- Have a documented internal complaint process
- Investigate issues promptly and professionally
🧠 The Toothcop’s Take
The future of Medicaid compliance in dentistry is: Smart, connected, transparent, and team-driven.
Wherever you practice dentistry, providers who invest in:
- Training
- Documentation
- Internal auditing
- Legal awareness
…are the ones who will thrive in this evolving landscape.
🦷 Stay sharp,
Duane Tinker – The Toothcop