As our client, you define our partnership based on your unique goals, requirements and level of expertise. We offer flexible program management options ranging from a software-only package to a full risk solution. Whether you select software-only, ask us to assume risk for all administrative and benefits costs, or choose an option somewhere in between, we pledge the same best-in-class service and administrative support. Program management options can even be assigned per market to maximize efficiency for each of those markets based on state regulations and demographic profiles.
Every level of program management includes the Enterprise System, our revolutionary dental benefits technology platform developed by our sister company Wonderbox Technologies. With it, we can advance every aspect of your program from cost containment and utilization management to regulatory compliance, fraud detection and member participation.
Our proprietary Focused Cost Containment program is one of the most effective, efficient tools for managing dental benefits in the industry. Utilizing innovative front- and back-end cost containment and over-utilization safeguards, we evaluate providers individually and apply appropriate authorization requirements based on each provider’s authorization and claim history. This targeted approach helps to reduce administration costs and enables us to focus clinical resources on providers with profiles and treatment patterns that warrant further evaluation and scrutiny relative to their peer groups.
Scion Dental’s utilization management is designed to ensure that care delivered to members promotes oral health, and that all dental services are necessary, appropriate, and delivered in the most cost-effective setting. These monitoring efforts are overseen by our Quality & Compliance Department.
Effective utilization management depends on robust claim processing. Scion Dental utilizes a three-tiered method for clinical review during claim processing, ensuring that all submitted authorizations are determined fairly, accurately and consistently. First, a series of pre-defined client-specific edits are automatically checked against all submitted authorizations. Erroneous submissions are then forwarded to Scion Dental’s trained clinical review specialists, who make determination decisions based on state and market regulations as well as any modified provider claims/authorization requirements. When authorization determinations are appealed by the member and/or provider, the case may be forwarded to a neutral dental consultant for review and final determination.
We comply with all recognized utilization management and review standards as they apply to dentistry, through federal and state regulations (including the Department of Labor ERISA regulations) and organizations like the Utilization Review Accreditation Commission (URAC). In fact, in 2013 Scion Dental became the first dental company to be awarded full accreditation for Claims Processing and Health Utilization Management by URAC.
Fraud, Waste & Abuse Detection
Scion Dental leads the industry in detection and prevention of fraud, waste and abuse related to dental care. In fact, Craig Kasten, Chairman of the Board and Co-Founder of Scion Dental, is recognized nationally for his work in raising awareness of pediatric dental fraud and abuse and his proposed solution to this urgent issue.
Our provider profiling capabilities, which are built into the Enterprise System, enable payers to rapidly identify potential offenders and take appropriate measures to minimize future instances. Functionality such as age-banded reporting can be easily implemented so payers can look at patients receiving an abnormal level of care in comparison to others’ within the same age band. Wonderbox Technologies, a sister company of Scion Dental, has set the industry standard for delivering this critical software innovation to protect our children.
Our new, proactive methodologies allow us to identify potential fraud and abuse faster than most other systems. By identifying aberrant utilization patterns early on, we help to deter abusive practices before client and taxpayer dollars are wasted.
Scion Dental is regarded by industry experts as the “safe choice” when it comes to compliance with new regulations and client business needs that require innovation. Our track record demonstrates that we have consistently completed new regulatory requirements well in advance of their effective dates. Our commitment to quality is reflected in our URAC accreditations. We are the first dental benefit management company in the United States to have been awarded URAC full accreditation for both utilization management and claims processing.
Grievances & Appeals
Member and provider satisfaction are key performance indicators integral to our quality program. To maintain high levels of satisfaction, our appeals department responds to every member or provider complaint, grievance and appeal quickly and thoroughly, delivering a speedy resolution. We inform members and providers of their full rights as they relate to grievances and appeals resolution, and we ensure they are treated with dignity and respect at all levels of the process. To assist clients in their efforts to address any ongoing service issues, we proactively track and report complaint and grievance trends to our clients.
Scion Dental uses multiple outreach tactics to communicate with members, provide education on the importance of regular dental care, and expand their access to care. Some of our core tactics include:
- The Member Web Portal, which offers members 24/7 access to relevant benefit information, educational links, online documents and education materials, and our Find-a-Provider search. This portal is quick, convenient and easy for members to use.
- Interactive Voice Response (IVR) Calling, which delivers automated messages that can easily be customized for a variety of situations and population sub-sets. At any time during these calls, members have the option of pressing “0” to be immediately connected to the Scion Dental call center to speak to a customer service representative.
- Text messaging and direct mail for targeted appoint ment reminders and member education.
Our member outreach is designed as an active, ongoing program in order to maximize its benefit to members and our clients.