The services offered by Dental Risk Company

Dental Risk Company offers a menu of various services to cater for the varying needs of its clients, which can be summarised as follows:

Option 1
  • Full dental administration (basic and specialised dentistry).
  • Capturing of paper claims and electronic claims.
  • Pre-authorisations (basic, specialised and in-hospital necessity).
  • Membership validations.
  • Clinical adjudication of claims (measured against established protocols).
  • Payment of dental providers and sending remittances.
  • Member and provider enquiries (including a call centre).

Benefits for the scheme include:

  • Fraud and over servicing are restricted. Tooth numbers are captured, and members and providers are profiled.
  • No expensive system developments for the scheme.
  • The scheme can concentrate on its core business cost drivers, such as hospital, pharmacy and specialists claims for other disciplines.
  • A reduction of expenses for the scheme.

Option 2- Capitation agreements
Dental Risk Company performs the same administration functionalities as in Option 1, as well as assuming the risk of covering all legitimate claims.

A fixed fee is payable to Dental Risk Company, per beneficiary per month, and all claims according to agreed benefits and tariffs are paid and covered by Dental Risk Company.

The client can decide whether services should only be rendered by Dental Risk Company’s Provider Network, or if members should rather have freedom of choice to go to a dental provider of their choice.

Benefits for the schemes include:

  • Dental expense for the scheme’s financial year is pinned, allowing the scheme to budget accurately.
  • A reduction of expenses for the scheme.
  • No risk for the scheme.
  • Network Option can be included (Please refer to benefits).
  • All administration for dental is covered in the capitation fee, reducing the scheme’s non-medical expenditure.

Option 3
Dental Risk Company offers clinical adjudication of claims on behalf of schemes prior to payment. This option allows the scheme or its administrator to apply basic administration such as member validation, checking for stale claims, and verifying benefits, to each claim.

Dental Risk Company will receive a claim file prior to payment on a daily basis and will import this in an agreed format into its system. It will clinically assess all claims against more than 1000 protocols to ensure that the claims submitted are clinically accurate. On completion of this, Dental Risk Company will return the claims on a daily basis with payment indicators for the scheme to pay the providers or members.

This option can also be linked up with pre-authorisations, where Dental Risk Company clinically approves or rejects authorisation requests from providers or members for certain high cost procedures such as orthodontic treatment, surgical extractions (and whether they should be in or out of hospital), crown and bridge work, to name a few.

Benefits for the schemes include:

  • The Scheme maintains control of the administration of its claims.
  • Dental Risk Company’s system is used to adjudicate the claims clinically.
  • A reduction of expenses for the scheme.
  • If the pre-authorisation section is chosen, this adds to the scheme’s IP and clinical capabilities without it having to enter into long term staffing contracts.

Option 4 – the Network Provider option
This option provides dental management on behalf of schemes. The scheme and its members are guaranteed that:

  • Dental services will be delivered according to the scheme’s tariffs, related to the scheme benefits wherever a contracted provider is used.
  • There will be no co–payments for items inside the scheme’s benefits.
  • Members will be informed when a procedure is not part of their benefit by the provider, prior to the work being done.
  • Providers will be profiled according to certain compliance and utilisation criteria, and this information is presented via quarterly feedback to the scheme, along with action plans and strategies to improve these levels.
  • Concise manuals are produced for service providers to ensure that they understand each schemes’ benefits, and that they can offer excellent service to each schemes’ members. The schemes are invited to take part in the production of these manuals.
  • Service complaints requiring investigation can be dealt with via Dental Risk Company, relieving the schemes’ call centres to concentrate on other disciplines.

Benefits for schemes include:

  • Members have guarantees of no out-of-pocket expense for covered codes as set out in the manual, provided that they visit a dental provider contracted to Dental Risk Company.
  • A reduction of expenses for the scheme.
  • A list of dental providers is available to members, making it easy for them to find a dentist in an emergency, on weekends or holidays, or when they have relocated.
  • Security for the schemes that the dental providers contracted to Dental Risk Company are monitored and managed to the benefit of the member and the scheme.
  • The dental service providers are managed and monitored continuously, making sure that each scheme’s members are only referred to dentists that are qualified, and that they meet strict service criteria. Dental Risk Company has a team of trained evaluators that constantly monitor the Network, taking the following elements into consideration:
    • Active compliance management.
    • Monitoring of trends constantly, to highlight potential over-servicing and fraudulent claims, for example.
    • Clinical evaluation and monitoring by in-house dentists and trained staff
    • Actions taken include peer-to-peer counselling, visits to dental providers and written communication. The type of problem that is experienced determines the nature of the intervention.
    • Quality control of the services rendered to the members of the schemes.
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