Practice Profiling

Profiling dental providers' utilization is the best way to determine if a dentist is complying with best practices. It is important to use a statistically valid methodology in order to accurately assess utilization. P&R's sophisticated profiling application, DentSource, will allow you to assess utilization by patient age, gender, region and specialty.

With P&R's system you'll be able to profile individual providers based on; overutilization, underutilization, fraudulent and abusive practices, upcoding, unbundling, provider gaming, denial rates and quality of care. Obtain individual provider scores based on utilization and claim review denial information and compare to national and regional benchmarks.

There is no better and more statistically valid way to control benefit costs.

Dental Claim Review Management System

Improve dental consultant claim review productivity without sacrificing quality. It takes well trained consultants and the right tools. P&R Dental Strategies has a variety of tools at our disposal that give dental consultants all that is necessary to complete efficient, effective claim reviews including, web applications for dental claim review management, policy information, audit trails and compliance with state laws.

Automate your claim reviews with P&R's professional Claim Review Management System (CRMS). Clients who use our system report they double the number of claims they review per hour and make far fewer mistakes.

The CRMS provides a complete audit trail and complete data storage solutions that can be customized. Our program was designed to be flexible. You can set up your CRMS for your individual degree of dental director participation; track prior claims, letter and phone calls; generate letters to insurance companies, providers and patients as required by law; meet deadlines with a built-in alert system that keeps track of turnaround requirements and create "case pending letters with the letter writing wizard.

Electronic Dental Claims

P&R's CRMS, a web-based application for claim review, allows you to submit dental claims forms in minutes. P&R can also support the submission of electronic attachments (x-rays, perio charts, etc.) By submitting claims electronically for review, consultants can make decisions faster. Automating the claim review process is essential in today's market and doing so will save you valuable time.

Actionable Intelligence

Actionable intelligence is information that's been analyzed so that strategic decisions can be made based on what's been found. If data analysis reveals a pattern that points to fraud or abuse, then action can be taken to stop and prevent further bad behaviors.

Another instance of actionable intelligence would be the use of utilization data to analyze the impact of plan design changes that could lead to decisions about benefit improvements. Or, analyze in-network and out-of-network utilization to make decisions about provider fees.

On-Site Consulting Services

P&R employs dental benefit experts, licensed dentists and information technology specialists to address your specific business needs. P&R has clinical and business expertise gained through more than 20 years of experience. P&R offers customized consulting services in the following areas; process management and engineering, utilization management, quality management, UM/UR program set-up, compliance improvement, dental plan design, claims system edit, clinical review criteria and plan committee services. Here is a closer look at how we can help your business with our expertise:

Utilization Review - Determine the most common items that require additional clinical review. Design and implement utilization review program. Assess quality and help select the quality reviewers. Develop and implement a program for state compliance.

Quality Assurance - Establish a quality assurance program that doesn't sacrifice member quality. Assess and rank order providers in network. Determine appropriate metrics to measure quality of care with providers.

Provider Profiling - Implement effective provider education programs. Perform statistical and programming analysis for profiling a network of dentists. Provide insights into practice patterns. Assess appropriate metrics with which to assess dentists.

Fraud and Abuse - Target providers whose practices appear to be submitting fraudulent or abusive claims. Develop methods by which to determine fraudulent and abusive practices. Provide expert testimony in cases of fraud.

Network Development - Develop metrics to be used to determine which providers should and should not be in your network. Determine appropriate targets for inclusion in the network. Assess a network's strengths and weaknesses and where improvements should be made.

Benefit Design - Design a benefit plan that offers employers the most benefits for their premium dollar.

Edit System Development - Institute and edit system that includes appropriate dental logic. Develop an edit system that reduces the requirement for additional clinical oversight.

Dental Claim Utilization Review

Outsourcing your utilization review to P&R is a smart business decision because P&R offers a 100% state compliant turnkey solution. P&R employs over 40 P&R accredited dental consultants with licenses in all states that require home state licensure. Our consultants average 25 to 40 claim reviews per hour with the lowest reconsideration rate in the industry.

Compliance

Compliance is a bothersome fact of life and there's no way around it. P&R Dental Strategies' professional claim review services are 100% compliant with all state turnaround time and home state issue requirements. P&R designed a web-based application to make compliance as easy as it possibly can be. Our Claim Review Management System (CRMS) allows dental consultants to spend their time on the review itself, instead of worrying about which letters to send to which states.

Non-compliance is extremely costly. Dental payers who don't comply with state laws face stiff penalties. Enforcement is on the rise. This means staying legally current, and thereby avoiding fines, is critical to a dental consultant's success. Our in-house compliance officer tracks the frequently changing dental compliance laws in every state. Compliance made as easy as pie so you don't have to eat the humble variety!

Dental Fraud & Abuse Detection

The best way to reveal problems in claim submissions is to identify specific patterns that point to fraud and abuse. P&R's global claims database and its tools will enable you to build a comprehensive picture of individual dentist practice patterns. Compare against national or regional databases. Construe detailed profiles of providers based on utilization ratios that investigate overutilization, underutilization, upcoding, unbundling and quality of care.

Evidence-Based Dentistry

Evidence-based dentistry is founded on determining appropriate treatments of care. Before determining best practices, you must understand how dentists treat patients in the real world. A national cross-payer, longitudinal database of patient information is the only way to truly assess how dental treatments are actually provided. Only then can decisions be made on appropriateness of care.

Digitize Dental X-Rays, Color Photos and Paper Documents

P&R has the very best in digital imaging. We recognized there was nothing on the market specifically designed to meet the needs of dental claim reviewers. Our programmers tailor-made a system that captures and creates the sharpest images available at the fastest speed in the industry. It's called the Rapid Review Imaging System (RRIS).

The RRIS handles color photos and paper documents as well as analogue x-rays. A user simply puts the document, photo or x-ray on a light bed and clicks "capture." The RRIS analyzes the object and determines all of the optimal camera and lens settings, self-adjusting to capture an image of inferior quality. Non-linear algorithms "read" the image to create the clearest diagnostic result possible.

Dental Claims Processing

P&R Dental Strategies is expert in dental claims processing and we know how to contain costs that can easily get out of control when your claims processing isn't set up most efficiently. Turn to us for consultative support or to help you design an internal system that will streamline the review process.

Dental Network Management

P&R has designed a web-based application that can help you choose providers according to criteria you determine is most important and best suited to your network. It's called DentSource and is an extremely useful tool for educating providers considered to be "outliers" who can be brought back in line with the highest dental practice standards.

Audit Trail Automation

Once you automate your claim review process, including an audit trail, you'll instantly reap the rewards. Clients who use our system report they double the number of claims they review per hour. P&R's Claim Review Management System is an industry-tailored program designed to give clients the utmost in maneuverability and customization. This sophisticated dental claim review system provides a complete audit trail and comprehensive data storage solutions.

P&R Accredited Dental Consultants

The task of utilization review should not be left to dental consultants who lack proper training. A payer's perception in the marketplace and financial implications are at stake.

P&R Dental Strategies employs a rigorous quality assurance program that begins when a dentist first seeks to become a consultant. A thorough in-house credentialing process begins and is geared toward determining the potential for a dentist to be a consultant reviewer. This is followed by a six-month training program under the watchful eye of the P&R Dental Director. Ongoing monitoring is supported by numerous reports, which provide real time feedback on the quality and consistency of the reviews.

Focused Review

A focused review involves utilization review of claims for procedures that are typically not subject to utilization review, but it's being implemented because a provider's utilization analysis indicates statistically abnormal trends or patterns.

Examples of procedures for which focused review is applied, include pulp caps, palliative treatment, examination problem focused, periodontal evaluation, restorations, pulpotomies, crown buildups, scaling and root planning, occlusal guards, full mouth debridement.

Directed Claim Review

There are three types of directed review:

• Limited Review
• Standard Review
• Extended Review

The decision about which type of directed claim review to proceed with is based on a provider's utilization patterns and claim denial rates. Procedures subject to directed review may, or may not be those typically subject to utilization review.

A Limited Review is appropriate for providers with low denial rates for specific procedures. Standard Review is applicable to providers who have denial rates within the norm. And finally, Extended Review is suggested for providers with high denial rates for specific procedures.

National Dental Claims Database

Use sophisticated data analysis to guide your decisions and take your company to the next performance level. Build professional provider profiles using comprehensive payer-specific or multi-payer longitudinal data. Customize standard claim review guidelines using statistically valid provider utilization studies.

A comprehensive multi-payer database of long-term patient history is essential to effectively support quality management, fraud and abuse detection and to serve as a starting point for evidence-based dentistry.