We offer just the right amount of assistance:

We will audit your dental program for you or provide just the needed components. For example, if you regularly do your own claims audits, we will work seamlessly with you by looking at the clinical appropriateness of the decisions to pay or deny claims.

Situation Report: Value added to a claims audit

The Situation: A client contacted their consulting firm, following recurring employee complaints regarding dental claims administration. The issues involved alternate benefit determination, and dentists' complaints to employees that benefit determinations were based on reasoning that was no longer clinically relevant.

The Challenge: Although the consulting firm was experienced with claims audits, a clinical perspective was needed to establish whether or not the carrier was making benefit decisions on the basis of appropriateness-of-care, and common industry practice.

Actions Taken: We complemented the claims audit by reviewing the administrator's clinical policies, and performed a focused audit to look for inappropriately adjudicated claims.

The Results: We suggested changes in policy, when benefit determinations were not consistent with current practice parameters or common industry practice. The carrier was on notice to fix processes that tended to delay or increase errors in claims adjudication, or risk loosing the business.

Contact us for more information about plan and claims audits.

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