Stopping Dental Insurance Fraud at the Gate

NEW YORK, Feb. 17 /PRNewswire/ -- When Dianne Rose, D.D.S., and her partner, Anthony Paciello, D.M.D., inaugurated P&R Dental Strategies, Inc. over 20 years ago to provide third-party claim review services for national insurance companies, trade unions, self-administered corporations and other dental claims payers, they could not have imagined how far they would eventually be able to take the art of insurance claim review.

"When we started," Dr. Rose says, "we were building upon the systems the insurance companies already had in place, but through creative mining of data and trends, were able to do it more efficiently and cost-effectively than our clients. But, through the years, with our growing understanding of the industry and deepening knowledge of how best to accomplish our job, we have been able to deliver ever more return on our clients' investment in us. And, now we can focus on those claims and providers most likely to exhibit aberrant billing practices."

According to the National Health Care Anti-Fraud Association, the most common medical fraudulent activities are 1) Billing for services/procedures/supplies that were never delivered; 2) Intentional misrepresentation of treatment or services provided to obtain a greater payment than that to which the provider is entitled to receive, and 3) the deliberate performance of unnecessary procedures for financial gain.

P&R Dental Strategies has been on the forefront of developing systems and techniques for routing out all three of these areas of dental insurance fraud, and with the suite of proprietary applications they now provide, are not only able to meet the need for fraud and abuse detection within the dental industry, but, with the new Pronto™ application, can maximize the ROI on utilization review.

Traditional industry claim review services rely on dental payers identifying a static list of services it believes are potentially fraudulent and abusive. Payers then route the claims with those services to reviewers who determine if the service is medically necessary or not. Rather than just review any claim based on standard referral guidelines, Pronto™ identifies the appropriate mix of providers and procedures that will yield the greatest savings.

Pronto™ algorithms are derived from a large cross-payer database that includes utilization data on almost every dental eservice provider in the country. This data is then analyzed, using proprietary algorithms, in real time by Pronto™, to identify those providers and procedures that may yield significant savings due to the unnecessary nature of those services.

"Our mission," Dr. Rose said, "is to save our clients as much money as possible without sacrificing quality of patient care. Cost containment has always been our primary purpose, and now, with Pronto™, we are able to take the services we provide to an entirely new level.

"We believe P&R Dental Strategies is the ultimate resources for dental benefit cost containment because we serve the dental benefits market with state-of-the-art tools and expertise that can deliver optimal cost savings without sacrificing quality of patient care. From the largest cross-payer dental claims database to our 'P&R accredited' dental consultants, we have the right solution for maximizing return on investment."

For more information visit the P&R website at pandrdental.com, or to arrange an interview with Dr. Rose or other P&R principals, contact George Thomas Wilson, [email protected], or 917 716-4205.

SOURCE P&R Dental Strategies, Inc.