Larry Jefferson, a Native patient with the Chickahominy tribe, is looking for a dentist again.
For years, Jefferson has relied on federal Indian Health Service-related coverage to get dental care near Richmond. But one clinic after another has stopped accepting the program, he said, because providers told him they were not getting paid.
He said he first went to Seven Pines Dental. Then he switched to Sandston Comprehensive Dentistry. Then he tried Maidstone Dental. Each time, he said, care started normally. Then months or years later, the clinic told him it could no longer take patients through the Indian Health Service program.
“I had to walk around with a tooth that was getting ready to become abscessed because I didn’t have anyone to work on it,” Jefferson said.
Multiple dental clinics outside Richmond told WHRO they have experienced months of delayed or unresolved payments through an IHS program meant to help Native patients get care from outside providers when services aren’t available via the IHS or tribal facilities.
The delayed payments have left clinics with thousands of dollars in outstanding balances, forcing some to limit or stop services for patients in the program.
Federal officials say they’re working on the problem, but advocates say it’s just the latest in longstanding problems with the Indian Health system.
Providers open care to IHS program, then hit a wall
Jaime Boone, billing manager at Maidstone Dental in New Kent County, said her clinic has nearly $40,000 in outstanding claims. Some claims date back to last year, she said.
Boone said her office has spent months trying to resolve the issue, including phone calls, weekly in-person meetings, emails and printed records of purchase orders, claims and explanations of benefits.
From October to June, she said, the clinic received payment for only about 15 of nearly 50 outstanding claims.
“We're reaching a point from a business perspective that we have to stop accepting this program because we're incurring more debt than what we are helping with the patients,” Boone said.
In order to get care through the outside providers, Native patients must first receive approval and a purchase order, then the clinic provides care and submits claims for payment.
That means IHS is aware of the expected cost before treatment begins, Boone said.
As of mid-May, Boone said, Maidstone Dental began seeing Indian Health patients for emergencies only and stopped providing preventive care through the program, a change she estimates could affect about 45 to 50 patients.
“We have no legal recourse, we can't report them to the insurance commission because it is a federally funded program, so basically we're sitting ducks and we're at their mercy,” Boone said.
Alexis Hardy, office manager at New Kent Family Dentistry, said her office also has unresolved claims for patients covered through Indian Health programs.
She said the clinic went through the credentialing process more than a year ago because there is a large Native population in the area — the Pamunkey tribe’s 1,600 acre reservation and the smaller Mattopani reservation are both adjacent to King William County— and the practice wanted to serve those patients.
But Hardy said reimbursement has become harder to secure over time.
“We don't want to have to not treat these patients,” Hardy said. “But we're not going to negate our standard of care according to insurance not paying whether they say they will.”
The payment problems have left Jefferson, the native man who's had to bounce from dentist to dentist, with fewer options.
He said he had to switch dentists four times, and at one point had to wait for another specialist after a root canal provider stopped accepting Indian Health.
Maidstone Dental was one of the last clinics he knew of in the Richmond area that still accepted the program.
“They said I could come, but I’d have to pay cash,” Jefferson said.
In a statement, the Indian Health Service Nashville Area Office said it is actively working to address payment delays.
“IHS is coordinating closely with Service Unit leadership, participating providers, vendors, and its contracted payment processor to improve claims processing, enhance oversight, and facilitate timely payments,” said IHS Public Affairs in a statement sent to WHRO.
The office did not answer questions about how many providers or patients are affected, how much money remains unpaid or when the delayed claims are expected to be resolved.
Payment issues aren’t new in Indian Health
Health advocates said the problem reflects a larger, long-standing gap in the Indian health care system.
Abigail Echo-Hawk, executive vice president of Seattle Indian Health Board and director of its research division, Urban Indian Health Institute, said the program is a familiar source of frustration for Native families across the country.
“This is not only the lived experience of myself, this is a lived experience of my father, of my grandparents,” Echo-Hawk said. “This is a longstanding issue across the Indian healthcare system.”
Echo-Hawk said the Indian Health Service has been drastically underfunded for decades.
A recent analysis found per-person federal spending for IHS was $4,140 in 2021, compared with $8,908 for Medicaid, $12,223 for the Department of Veterans Affairs and $15,094 for Medicare.
Because IHS and tribal health systems often do not have enough providers, patients are regularly referred to outside clinics for dental care, specialty care or emergency services.
But those referrals come with a complex approval and reimbursement process. Echo-Hawk said patients may need to meet requirements such as residency rules and notification deadlines.
Even then, payment is not guaranteed.
“You may file it in time, but that wasn’t one of the priorities of that region, and so they’re not going to reimburse it,” Echo-Hawk said.
IHS is also the payer of last resort, meaning other coverage, such as Medicare, Medicaid, private insurance or veterans benefits generally has to be used first.
Echo-Hawk said that can leave patients and providers stuck in a long process of figuring out who is responsible for the bill.
“It creates a maze for the patients and for the providers to get the appropriate reimbursements,” Echo-Hawk said.
When providers stop accepting patients because they are not getting paid, she said, Native patients lose access to care and the burden shifts elsewhere in the health care system.
“That increases the ongoing chronic health disparities of Native people who simply now can't even get access to care,” Echo-Hawk said.
Kasey Jernigan, associate professor of anthropology and American studies at the University of Virginia, said Virginia faces a particular challenge because tribal health infrastructure in the state is still developing.
Many of Virginia’s federally recognized tribes gained federal recognition only in recent years. Unlike states such as Oklahoma, Jernigan said, Virginia does not have a large Indian Health Service hospital system.
That means many Native patients in Virginia rely heavily on outside providers, including local dentists and specialists.
“It can mean having to travel farther, to wait longer, sometimes months to years, having their treatment delayed, or simply going without care,” Jernigan said.
