ADA raises concerns about CMS CRUSH initiative proposals affecting dentistry

The ADA is urging the Centers for Medicare & Medicaid Services to carefully consider the impact on dentistry as it develops its proposed Comprehensive Regulations To Uncover Suspicious Healthcare, or CRUSH, initiative. 

The CRUSH Initiative is a sweeping anti-fraud program launched by CMS. In combating waste, fraud, and abuse, CMS hopes to leverage advanced AI and real-time data analytics to flag and stop suspicious payments across Medicare, Medicaid, and the Health Insurance Marketplace before taxpayer funds leave the system. CMS released a Request for Information (RFI) to solicit stakeholder feedback on additional tools that could be used to combat fraud.  

In comments submitted March 27 in response to CMS’ request for information, the ADA expressed concerns that several ideas under consideration could have unintended consequences for dental practices and patient access to care. 

Among the issues highlighted is a potential requirement that all providers enroll in traditional Medicare as a condition of participating in Medicare Advantage plans. The ADA said such a policy would likely discourage dentist participation, noting that routine dental services are not covered under traditional Medicare and many dentists therefore do not enroll in the program.  

“The ADA does not believe an additional enrollment process will meet CMS’s goal of reducing fraud, waste, and abuse,” the letter states, adding that most improper payments in Medicare Advantage are largely tied to risk-adjustment payments tied to upcoding medical diagnoses rather than billing fraud in supplemental benefits.  

The Association also noted that dentistry does not typically rely on diagnostic coding in claims submissions, further limiting the relevance of such a requirement. 

The ADA warned that imposing dual enrollment could reduce the number of dentists participating in Medicare Advantage networks, potentially undermining CMS efforts to improve network adequacy and access to care for beneficiaries. The letter also pointed to longstanding concerns about inaccuracies in the Provider Enrollment, Chain, and Ownership System (PECOS) used in Medicare, suggesting that expanding enrollment alone may not strengthen fraud prevention. 

CMS also sought feedback on whether to expand authority for Medicare Advantage and Part D plan sponsors to suspend payments to certain providers. The ADA said this could disproportionately affect dental practices, which generally participate only in Medicare Advantage through supplemental benefits.  

“Payment suspensions made liberally by [Medicare Advantage] plan sponsors could have severe financial consequences for dental practices, particularly small or solo practices,” the letter states.  

The Association emphasized that many practices operate with thin margins and depend on steady reimbursement to cover expenses, meaning even temporary suspensions during investigations could disrupt operations regardless of the outcome. The ADA recommended that any such authority not apply to supplemental dental benefits. 

In addressing the potential use of artificial intelligence to enhance program integrity, the ADA acknowledged the promise of AI tools but cautioned that dentistry faces significant limitations related to data quality and interoperability. Dental claims data are primarily structured for benefit administration, the ADA said, and are not well-suited for determining medical necessity or detecting fraud. The Association also noted that dental data systems are often fragmented and lack standardized formats, making them difficult to use for AI development. 

The ADA recommended that CMS support investments in dental data infrastructure and require independent validation of AI tools. It also urged the agency to prohibit insurers from using AI as the sole basis for claim denials or prior authorization decisions, warning that such use could lead to increased administrative burden and potentially unfair outcomes for dentists. 

The letter encouraged CMS to improve program integrity by promoting centralized credentialing in Medicaid programs to reduce administrative inefficiencies and inconsistencies. Additionally, the ADA called for medical loss ratio/dental loss ratio to be attached to stand-alone dental plans (SADPs) offered through individual or small group marketplace exchanges to ensure a greater share of premiums is directed toward patient care. ADA noted that MLR/DLR requirements are already imposed on SADPs that administer benefits under Medicare Advantage supplemental benefits and Medicaid managed care and could be easily replicated within plans sold in individual or small group marketplace exchanges.