Led the policy advocacy, payer negotiation, and systems buildout that produced Hawaii's first PPS-reimbursed tele-dentistry claim — transforming a grant-funded pilot into a permanent care model for rural children.
WHCHC is a Federally Qualified Health Center serving rural communities on the west side of Hawai'i Island — one of the most geographically isolated healthcare markets in the United States. Like most FQHCs, it operates under HRSA's Prospective Payment System (PPS), which reimburses at a fixed per-visit rate regardless of service complexity.
In 2019, WHCHC was running a promising tele-dentistry outreach program — delivering preventive dental care directly into preschools, daycares, and WIC offices — but entirely on grant funding. The program had no billing infrastructure and no Medicaid reimbursement pathway. Every dollar of care depended on a grant that could expire.
"Tele-dentistry reimbursement didn't exist yet in Hawaii's Medicaid framework. We had to build the precedent while running the program."
The barriers weren't operational — they were structural. Medicaid had no defined reimbursement pathway for tele-dentistry encounters at FQHCs. State policy was ambiguous. Initial claims were denied as non-covered services. And FQHC rules required face-to-face encounters for dental reimbursement — a definition that needed to be updated before a single claim could go through.
At the same time, the clock was ticking. The $300K/year Hawaii Dental Services grant supporting the program was not guaranteed to continue. If reimbursement wasn't established, the program would end when the grant did.
| Area | Before | After |
|---|---|---|
| Reimbursement | $0 — 100% grant dependent | PPS rate per tele-dentistry encounter |
| Medicaid policy | No defined pathway — claims denied | State memos issued, eligibility clarified |
| Billing systems | Not configured for telehealth workflows | Custom payer builds across Dentrix, Dentacon, Intergy |
| Program sustainability | Grant expiration risk | Self-sustaining reimbursement model |
| Staff documentation | Forms labeled services as "free" | Updated workflows, billing-ready documentation |
| Place-of-service coding | Standard inpatient billing logic | Telehealth-specific POS codes implemented |
Getting a first-ever PPS tele-dentistry claim paid in Hawaii required aligning stakeholders who had never coordinated on this problem before.
Most billing problems are solved at the claim level. This one had to be solved at the policy level first — then rebuilt downward into systems and workflows.
Participated in discussions with Hawaii Medicaid leadership — including the State Medicaid Director — to advocate for recognition of tele-dentistry within PPS reimbursement structures. Translated evolving legislation into the specific operational and billing requirements needed to make a valid claim.
Challenged initial denials with documented clinical and policy rationale. Designed test claim strategies to probe coverage criteria and identify the exact conditions under which a claim would be accepted. Each denial was treated as information, not a dead end.
Built custom payer configurations across Dentrix, Dentacon, and Intergy to support tele-dentistry workflows. Implemented telehealth-specific place-of-service coding and itemized billing in place of standard Medicaid roll-ups — the only format that would pass claim adjudication.
Retrained clinical and administrative teams on documentation requirements. Updated patient forms that labeled services as "free" — which was accurate for patients but was blocking revenue capture. Resolved backlog and corrected legacy processes that predated the billing build.
Worked a claim through the full adjudication process — documented the attempt, payer response, and outcome at each step. The first PPS tele-dentistry claim was paid on July 11, 2019, establishing the precedent that made every subsequent claim possible.
Beyond the financials, the program remained operational — continuing to deliver preventive dental care to children in preschools, daycares, and WIC offices across rural West Hawaii. The billing infrastructure built for WHCHC also created a documented pathway that other FQHCs in Hawaii could follow.
This project was executed within an FQHC — a larger organizational context than a typical independent practice. The core challenge, however, is one that smaller practices face every time they try to bill for a service that doesn't have a clean reimbursement pathway: navigating payer ambiguity, challenging denials, and building systems that didn't exist before. That's the work.
Denial patterns, gray-area services, coverage disputes — this is exactly the kind of work we do. If your practice is losing revenue to claims that should be paid, let's talk through what's actually happening.
Book a discovery call →30 minutes. We'll tell you whether we think we can help.