Waste, Abuse and Fraud represents 10-14% of your total dental spend and in some cases may reach 25% for a total dollar amount of $12.5 billion per year.
ROI of Waste, Abuse and Fraud Detection
The current “pay and chase” approach is inherently inefficient. Paying the providers and then chasing those providers years later is very expensive and at best will result in a recovery of pennies on the dollar many years after the fraud is committed. When you read about a provider who was convicted of $1 million in Waste, Abuse and Fraud via the “pay and chase” process, the amount of the $1 million that is actually recovered is a very small percentage.
In contrast, DentaLens identifies the Waste, Abuse and Fraud early and permits the payer to intervene early when the Waste, Abuse and Fraud is still small amounts of money. Stop Waste, Abuse and Fraud payments at this stage and small problems never get a chance to grow into large problems. Because DentaLens identifies ALL the providers who are submitting Waste, Abuse and Fraud claims, early intervention prevents a large dollar loss (a small dollar loss per provider times a large number of providers equals a large dollar loss). Furthermore, since the Waste, Abuse and Fraud claims are never paid, the payer saves the entire Waste, Abuse and Fraud amount over a large number of providers.DentaLens provides large savings that are dollar for dollar saved… not pennies on the dollar.
With fully implemented DentaLens solution*, you could attain an ROI of 7 to 1 or more.
DentaLens’ Multi-Vectored Approach will tell you exactly who has committed Waste, Abuse and Fraud, what was fraudulent, when it happened, where it happened, and how it happened. The result is that DentaLens detects the maximum number of providers who are misusing the system with great precision.
The loss of Small Dollar Amounts across many providers will become Large Dollar Amounts over time
The majority of dollars that are lost to Waste, Abuse and Fraud can be attributed to a large number of providers who are constantly defrauding payers of small amounts of money on a continuous basis. These providers are NOT hardened criminals but rather basically honest providers who are taking advantage of vulnerabilities in the system. The DentaLens solution solves this problem by detecting patterns that indicate potentially bad behavior across all providers. If these incidents are detected early, immediate action can be taken preventing this from happening again.
Recovery of Historical Fraud
The essence of Dentalens is to develop better providers by educating them to submit only legitimate claims. This is the only way that will lead to significant reduction in Waste, Abuse and Fraud. DentaLens is an additional way to deal with the problem of Waste, Abuse and Fraud.DentaLens is NOT meant to completely replace the “Pay and Chase” model because “Pay and Chase” still has value. Rather DentaLens is meant to work in parallel with and to supplement “Pay and Chase”. DentaLens, in its normal operations, identifies historical instances of Waste, Abuse and Fraud that may have been overlooked because of the demands and limitations of “pay and chase”. In such instances, DentaLens provides the detailed evidence of historical Waste, Abuse and Fraud that can be recovered by the “pay and chase” method.
When the bulk of your losses comes from a large number of basically honest providers who are constantly defrauding payers of small amounts of money on a continuous basis, it is counterproductive to use the threat of criminal prosecution as the initial step to stopping the fraud. Dentalens believes that the best way to stop these losses is through better provider management. We achieve this with our optional Provider Relationship Management module by:
- Real-time provider communication upon detection of a potentially fraudulent act
- Providing these providers with sufficient evidence of their potential wrong doing.
- Once an Waste, Abuse and Fraud act is confirmed, offer the bad acting provider an easy way out of trouble by addressing the issue and push them to submit only legitimate claims.
- Escalating the tone of the provider communication starts starting with a non-accusatory tone and escalating in stages until the final stage if necessary, which is referral for criminal prosecution.
The early stage provider communication is designed to address the remediation of honest errors (clerical, poorly trained staff). The middle stages seek to address the problem through retraining and re-education. The later stages are designed to alert the bad acting provider that DentaLens has exhausted honest remediation and that only a deliberate act of Waste, Abuse and Fraud can explain the ongoing resistance to change. The goal is to build a better and trusted bond with providers so they will only avoid submitting suspected and fraudulent claims.
DentaLens’ comprehensive solution is complementary to what you already are using, providing support across your entire organization
The DentaLens solution is a complimentary solution to what is already being used in your organization today. Our near real-time detection system is fully automated and provides 100% coverage on all dental claims being processed every day – – prior to payment. The DentaLens multi-vectored approach provides immediate detection of all issues including the low-dollar, high-volume issues which account for 80-90% of total dental industry abuse, waste and fraud in your organization today.
Chief Dental Officer
- Allows limited resources to focus on strategic initiatives,
- Allows increased visibility into your provider network.
Chief Financial Officer
- No up-front cost to initiate the solution,
- 5% – 7% payout in savings based on detection of issues,
- Savings is recognized immediately rather than years later.
Chief Operating Officer
- No system integration is required,
- No process interruption occurs,
- Limited resource requirements.
- Provides further insights into the provider network,
- Provides provider management through communication, education and incentives,
- Provides a positive behavior change in your providers.
Special Investigative Unit
- Provides SIU teams with further evidence to support high-dollar issues of waste, abuse and fraud.
- Helps recover more money based on deep historical analysis,
- Identifies fraudulent networks as they develop.
The DentaLens solution can be used effectively by novices. Almost every task or query in DentaLens can be performed with the click of your mouse.
All of the hard work is done in the background so the user does NOT have to interpret any results. The results are converted into colored circles that each represents a provider, while the color of the circle tells the user if there is Waste, Abuse and Fraud.
The three colors used for detection are those that every individual can clearly associate with other areas of their everyday lives. A green circle means that a provider is fine and no fraudulent activity has been detected. A yellow circle represents a provider whose actions are borderline and may need to be looked at further. Finally, a red-colored circle indicates that DentaLens has determined that this provider has committed a bad act and intervention is required immediately.