Health plans increasingly face shrinking budgets and rising member expectations. A proactive regulatory compliance process and a fraud, waste and abuse (FWA) strategy can make a big difference in the quest to advance quality care while increasing efficiencies .
A forward-looking approach is especially critical in the highly competitive Medicare market, where innovative dental benefits administration practices can add immense value. The right single-source dental benefits provider can help ensure that your program keeps pace with changing requirements by tracking federal regulation and legislation pertaining to Medicaid, Medicare, Commercial, CHIP and the exchanges. At the same time, a benefits provider can and should deploy leading-edge monitoring and detection and reporting methods that uncover compliance issues early and enable swift corrective action.
As the leading dental benefits administrator in the nation, DentaQuest has had the opportunity to help shape some of the industry’s most progressive compliance and FWA strategies. We’ve identified three important things you, with the support of a strong partner, can do to create a compliance program that ensures quality dental care for your members and more value for your plan.
Create a Culture of Compliance
One of the critical responsibilities of an effective dental compliance program is to prepare the organization to conduct business in accordance with applicable federal, state and local laws. To do this, it’s important to create a culture of compliance that coordinates policy setting, training, oversight and reporting for maximum impact. This integrated approach will help avoid costly issues that hurt the bottom line while ensuring the integrity and quality of operations.
This is a big undertaking and, to achieve it, you need dedicated dental benefits partner resources with the experience and scale to seamlessly manage high-integrity program policies and procedures on the ground. (Strong communication with upper management is important, too.) Typically, the responsibilities of this team of experts include:
- Establishing written policies and procedures
- Developing effective communication practices for incident reporting
- Organizing training and educational sessions
- Proactively identifying and targeting compliance risks
Your dental partner should also be well positioned to forge close working relationships with government leaders and entities such as Inspector General Offices, State Attorneys General and CMS. The partner’s contacts, systems and processes should enable them to stay well-informed about the regulatory, national governance and legal shifts that may affect you — and continually evaluate best practices that could be used to your benefit.
Establish Robust Auditing and Monitoring
The right dental partner will make it a top priority to continuously monitor daily business functions and employee activity to ensure compliance with statutory requirements and contractual obligations. Routine employee and system reviews, clear written policies and procedures, and the leadership of a compliance committee that provides guidance and oversight form the basis of any effective compliance program.
Use of advanced business analytics, industry standard auditing, and robust oversight of providers will ensure greater utilization management accuracy, increased claims submission quality, and real time detection of potential fraud, waste or abuse. Every strong dental administrator maintains a process to audit and/or monitor its performance throughout the life of the contract.
Be Ready to Take Swift Corrective Action
While proactive prevention of non-compliance should be the goal of any dental benefits partner, it is important to know that your partner is prepared to spring into action with a well-formulated plan to address any when a potential risk arises. This means having a dental benefits partner who understands how to:
- Evaluate and analyze incident
- Define an actionable response plan
- Remediate the issue; and
- Test to ensure effective resolution
A dental benefits partner whose leadership maintains accountability for performance through robust policies and tracking performance against metrics is essential to preventing non-compliance. However, a partner who understands how to escalate significant issues or concerns and effectively develop and implement corrective actions will ensure that your Medicare operations remain in compliance.
Regulatory compliance and FWA strategies are critical to the integrity and health of your Medicare plan. The right dental benefits administrator will excel at creating a culture of continuous compliance, ensuring program and provider integrity and identifying issues early so they can take them to a swift resolution.