DentalClaim Insight™  is a prepayment fraud, abuse and overpayment prevention service designed to maximize dental claims payment accuracy, identify fraudulent providers and reduce dental benefit costs.  This service combines HCI’s cutting-edge Code Validator Pro™ (rules-based) and Fraud Finder Pro™ (profiling) software systems with claims review by Dental Coding Specialists/Certified Dental Consultants and suspect provider validation by a Clinical Investigative Unit (CIU).

Service Results

• Increase profitability – Average annual payor savings of 4%-10%
• Reduce PMPM expenditures - Savings from $1-$4 PMPM
• Greater claims payment accuracy – Impact up to 10% more claims
• Identify fraud with greater efficiency – Eliminate up to 95% of false-positives

Service Features

• 100% of dental claims analyzed
• Review by dental coding specialists on all suspect dental claims
• Code Validator Pro™ software applies rules based on ADA/CDT coding descriptions and guidelines and proprietary databases
• Overnight claims turnaround and reporting
• Clinical support and response for provider appeals
• AADC Certified Dental Consultant review and support
• Highly customizable rules and parameters
• Clinically derived unbundling and mutually exclusive service rules/edits
• Fixed and contingency-based fee models

Analytic Features

1. Clinical Investigative Unit (CIU) review and validation on all suspect provider activity
2. Fraud Finder Pro™ software delivers real-time daily provider scoring and dynamic profiling
3. Application of new conditions based on billing trends, fraud scores and clinical validation
4. Daily notification to clients of new suspect providers and claims identified for review
5. Identification and verification of federal and state sanctioned providers, deceased providers/patients and Specifically Designated Nationals (SDN)
6. Auto-generated statistics, graphs and reports for easy interpretation and assessment