How DentaQuest Is Taking On Fraud, Waste, And Abuse

by Nick Messuri, DentaQuest

August 8, 2017

Providers, managed care organizations, and many other health care stakeholders are increasingly tasked with achieving more on shrinking budgets, placing a premium on models and strategies like anti-fraud, waste, and abuse (FWA) that improve outcomes while containing costs.

But what makes for an ideal anti-FWA program? For starters, it is relationships. Stakeholder relationships are instrumental in determining and implementing best practices. And our fraud prevention and recovery unit has proven those best practices ensure optimal, most appropriate care for patients and tremendous value for our clients.

For example, based on 2015 data, DentaQuest’s robust anti-FWA activities were able to deliver $62.8 million in total annual savings for one of our state partners. We administered dental benefits to 1.6 million Medicaid and CHIP members in that state, processing $640 million in claims annually.

One of the keys to the development of DentaQuest’s comprehensive anti-FWA program is the strength of our relationships. We have built strong internal and external partnerships that lead to substantial FWA prevention and cost savings. These relationships allow us to enforce program integrity standards through prevention, as opposed to counter-response.

  • Internal communications promote compliance and program integrity, monitoring, awareness, and detection. This exchange of information is constant within DentaQuest among key company departments that include: Fraud Prevention & Recovery (SIU), Compliance, Utilization Management, Complaints and Grievances, and Business Analytics.
  • External communications with key state and federal agencies garner intelligence gathering, strong enforcement and deterrence. DentaQuest maintains a close working relationship with state Inspector General Offices, state Attorneys General, Medicaid Program Integrity, and the federal Centers for Medicare and Medicaid Services (CMS).

But there is more to it beyond relationships, or rather in conjunction with these relationships. Promoting prevention of FWA entails:

  • Training employees on our values and policies regarding program integrity and their responsibilities to detect and report FWA;
  • Operating a credentialing and re-credentialing program with regular monitoring, which ensures only providers who practice with integrity are put on our network;
  • Creating a comprehensive utilization management program, which combines prior authorization requirements and prepayment reviews to make sure services are medically necessary; and
  • Applying a diverse range of claims processing controls, algorithms, and edits that factor in investigation results.

DentaQuest’s FWA detection, prevention, and investigation strategies are data-driven and based on our diverse partnerships that span 30 states. Because of our engagement with key stakeholders, we are able to effectively reduce FWA not just for DentaQuest clients, but indirectly for the entire U.S. health system.

DentaQuest also invests in the long term. We dedicate company-wide resources to FWA prevention, detection and enforcement. We reduce costs through audit planning, exposure assessments, investigations and recoveries. We prevent illegal activities through compliance, awareness, education, behavior modification, and a 30-year inventory of analytics that has the intelligence to block reimbursement for inappropriate services. We constantly aggregate our national data findings and nurture our algorithms to provide a best-in-class dental anti-FWA program that identifies outlier behaviors and risk indicators. We also measure all of this pre- and post-payment savings for our clients.

This expansive expertise enables us to help push the health care industry forward. We ensure optimal care for our beneficiaries while simultaneously reducing inefficiencies and allowing our partners to reinvest their savings into new, innovative models that improve population health.

Nick Messuri is Vice President of Fraud Prevention and Recovery at DentaQuest.