When dental care fraud or abuse occurs, everyone pays the price. At SKYGEN, innovative, technology-enabled strategies enable our clients to better protect their members and provide access to quality, appropriate care at reasonable costs. Let’s do more than talk about stopping dental care fraud and abuse – let’s end it.
Commercial and government dental payers share a common goal: Provide high quality, appropriate and effective dental care while containing benefit and administrative costs. One strategy all payers can pursue with this goal is mind is detecting and preventing fraud and abuse. And they need to. The National Health Care Anti-Fraud Association estimates that dental fraud, waste and abuse costs approximately $12.5 billion, or 5% of total spending on dental care in the U.S. each year. The media continually reports on cases of dental fraud and abuse, particularly involving children and adults with lower levels of healthcare literacy. Both patient populations are at higher risk for receiving overtreatment and inappropriate dental care. Fortunately, with advances in technology and analytics there is now more opportunity to identify and reduce dental fraud and abuse.
An Innovative Solution
SKYGEN’s Enterprise System and data analytics power three data-driven strategies to combat fraud and abuse and improve access to high-quality, appropriate dental care at reasonable costs. United under the SKYGEN Provider Select Suite, these proactive strategies align provider, member and payer interests. These strategies include:
The Ratings Tool helps payers reduce inappropriate care and its associated costs by identifying variances between providers within the program. Providers are rated on criteria such as appropriate care, cost of care, member feedback, degree of electronic adoption, and more. The criteria are weighted to align ratings with the payer’s specific program goals. Armed with this data, payers can shift members to high-performing providers delivering the most appropriate and cost-effective care. They can also align other providers with program goals by educating them on ways to improve their ratings.
The Recognition Program tailors a recognition and reward strategy to payer goals to help align providers with these goals. Providers that deliver high-quality, cost effective care earn recognition, which can drive higher patient volume and preferred provider status. Payers have the option to integrate automated value-based reimbursement programs as well that leverage the Ratings Tool data.
With SKYGEN’s Enhanced Find-A-Provider solution, payers gain significant cost savings by directing members to nearby providers that offer the most appropriate and efficient dental care. What makes this solution different from traditional location-based find-a-provider tools is the integration of provider ratings. Members’ self-service inquiries return the optimized blend of quality care and travel time for each individual member. Enhanced Find-A-Provider enables payers to be more proactive in ensuring appropriate care and in increasing member satisfaction. As the table below shows, this data-driven strategy can also reduce the cost of care significantly.
Source: Modeled by SKYGEN using actual provider data.
Shifting Members to Highest-Performing Providers Reduces Cost of Care
Even if payers direct a small portion of members to higher-performing providers, everyone benefits – members, providers and payers. At SKYGEN, we believe this alignment of interests is an essential driver for reducing fraud and abuse in dental. With the integration of technology and advanced analytics in dental benefits administration, this goal is now more achievable than ever for payers.