The National Health Care Anti-Fraud Association estimates that of the $250 billion spent on dental care procedures each year, $12.5 billion (or 5 percent) is lost to dental fraud and abuse. This is a significant challenge for the entire care delivery system, including payers, providers, and patients. A problem of this magnitude requires a coordinated approach that leverages the best data assets, analytic models, technology, and expertise the industry has to offer.
Verscend Dental Accuracy is an all-in-one offering of dental claim editing, clinical validation services, consulting, and fraud detection that helps contain dental costs. Advanced algorithms, applied to nationally sourced and proprietary edits, flag potentially incorrect claims on which our team of licensed dentists, dental coders, and specialists can make payment recommendations within hours.
Based on CDT language, best practices, and standards of care, our edits identify situations such as unbundling of codes and global follow-up periods. As a backup to internal adjudication processes, our system also edits on age limitations, frequency of services, and other scenarios based on plan language. Auto-adjudicated edits are returned to the client immediately, while claims requiring manual review are pended for our clinical review workflow.
Verscend’s clinical and coding experts constantly maintain the content supporting the rules and edits, including additions and changes to industry code sets. We regularly make updates, which do not require client involvement. Clients may also request edit customizations to align edit logic with their own reimbursement policies.
Dental claims that cannot be auto-adjudicated enter our clinical review workflow, where Verscend’s clinical expert analysts and dental coders look closely at triggered anomalies based on nationally recognized coding and clinical guidelines. Verscend returns payment recommendations to the client within hours of receipt and processing into our systems.
Verscend’s team of licensed dentists handle claims requiring additional clinical analysis or medical necessity review.
Verscend’s dental and coding experts partner with clients through frequent consultations and quarterly review meetings. These interactions help to identify new editing and savings opportunities, as well as customized edits to adhere to client payment policies.
We also run claims through our advanced fraud analytics engine for scoring and analysis of dentist billing behavior that may be potentially fraudulent. Verscend employs a dedicated team of clinical analysts and fraud experts within our own clinical investigations unit (CIU) to review and validate our results prior to sending them to the client’s SIU. Clients can then focus on only the dentists and claims identified as suspect, reducing wasted time on false positives and increasing case open rates. We also adjust edit scrutiny accordingly.
Verscend’s payment recommendations are sourced from nationally recognized coding standards to ensure that denials and reductions are defensible. When dentists appeal these decisions, Verscend’s clinical experts process appeals on behalf of our clients, providing additional rationale to support our coding and payment recommendations.
Verscend provides monthly operational reports as well as an annual savings review.
Dental Accuracy is part of Verscend's suite of end-to-end Payment Accuracy solutions. Because the solutions all share one data feed across integrated platforms, clients can take a prioritized, incremental approach to rolling out our full suite of offerings. In other words, once you have one component up and running, others can easily be turned on without an additional implementation process. This approach allows you to launch new capabilities faster while saving you money.
Rather than standard software license fees, our Dental Accuracy solution is priced as a contingency contract. This approach aligns incentives between Verscend and our clients.
Verscend saved one client $2.6 million in 2016 through dental claim editing and clinical review.*
*Based on actual client results. Individual results will vary by client.
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