Solution

Our distinctive approach for combatting

Waste, Abuse and Fraud combines informatics,

clinical expertise, forensics, information technology

and advanced data visualization

DentaLens is the First near Real-Time Dental Waste, Abuse and Fraud Detection and Prevention Software Solution.

DentaLens is a one-of-a-kind software solution that enables dental payers to finally make a huge impact on waste, abuse and fraud by moving from a “pay and chase” and “manual review” model to an automated “detect and prevent” model. DentaLens’ complete solution that includes a near real-time detection system and a Provider Relationship Platform (PRM), after many years of research and development, is specifically designed to address the financial burden caused by pre-payment of the high volume, low dollar as well as the low volume, high dollar waste, abuse and fraud that exist within the dental industry today. It is estimated that up to 90% of all dental waste, abuse and fraud is low dollar claims that are not being addressed today.

DentaLens’ sophisticated near real-time detection system is developed through a combination of the following attributes:

  • Clinical Knowledge
  • Informatics
  • Forensics
  • Information Technology
  • Advanced Data Visualization

Using this unique combination, DentaLens has developed a multi-vectored (multiple angles/scenarios/algorithms) approach that reviews all claims from all dental providers within hours, detects, and provides the exact details of Who, What, When, Where, and How dental billing issues take place. This unique multi-vectored approach is administered pre-payment and pre-adjudication saving the dental payer millions of dollars.

DentaLens findings (reports) are then fed real-time into our innovative Provider Relationship Management platform. The PRM platform is an optional module that can be used to achieve a behavioral change in the providers through communication, education and incentives that entice the provider to stop submitting questionable claims. PRM tracks the billing issues over time, identifies any changes in provider behavior and triggers an escalation of communication between the Provider and Payer. The end result is that DentaLens provides a complete solution that changes the current “pay and chase” and “manual review” model to an automated “detect and prevent” model.

Despite years of effort and a multitude of variations of the “pay and chase” model, the percentage of success as reported by the Office of the Inspector General (OIG) of Health and Human Services for 2013 was less than 6% of the total estimated healthcare fraud.

When the “pay and chase” results of 2013 are compared to the entirety of waste, abuse and fraud, the success rates drop to a dismal 0.6%. This methodology requires the use of highly trained, expensive professionals using very powerful yet difficult-to-use software to process the mountains of data that are needed to meet the evidentiary requirements to make the “pay and chase” model effective. Thus it is impractical to use “pay and chase” to deal with any small dollar waste, abuse and fraud, which is prevalent in dental claims.

To truly make an impact against dental waste, abuse and fraud, the system must take a look at all claims before the provider is paid. DentaLens supplements the “pay and chase” model with a more proactive approach that attacks the problem of small dollar billing issues as well as large dollar issues at the onset. DentaLens identifies the waste, abuse and fraud early (near real-time) before it gets out of control when the issue is still a small amount of money. Stop improper payments at this stage and small problems never get a chance to grow into large ones. DentaLens was designed to detect waste, abuse and fraud early which allows early intervention with the provider. This is the essence of the DentaLens proven “detect and prevent” solution.

Healthcare data is both an abstraction and a representation of a real event. We at DentaLens understand this and together with clinical experts, are able to reconstruct this event.

DentaLens applies its Multi-Vectored technology (multiple smart and connected algorithms) on all dental claims data, flagging the suspicious claims within hours with the exact details of who has committed issue, what was at issue, when it happened, where it happened and how it happened. The results are then organized into a visual display dashboard that is easy to understand and easy to use.

Once the waste, abuse and fraud data has been collected, our clients have an option to use our Provider Relationship Management (PRM) platform. The PRM is an optional behavior change module offering provider communication, issue escalation, monitoring, and provider-level analysis. The module is an innovative and first-of-its-kind solution to help manage the suspicious claims and questionable providers by offering the provider an opportunity to address the issue by resubmitting appropriate claims, where necessary. PRM also identifies the good providers who can be incentivized to continue their appropriate billing behavior. Last but not least, for those providers that do not address the issues that DentaLens has determined problematic, the DentaLens PRM will provide enough evidence to support legal action, as payers deem appropriate.

DentaLens is a customizable system that detects and prevents waste, abuse and fraud occurring in dental provider claims.

We also understand that there may be challenges specific to your organization that are not adequately addressed by our included algorithms. In such cases, we are able to modify an existing algorithm or develop an entirely new algorithm to focus on your particular concerns and plug this into our existing DentaLens near real-time detection system.

Thus you retain all the existing benefits of DentaLens PLUS receive the added benefit of our customized plug and play algorithm.