Dental Insurance Challenge
Health insurers & dental coverage
Health insurers transformation
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The transformation of health insurers from simply fulfilling the role of financial backers to taking on the role of life partners signifies a considerable change in the direction of the industry.
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Health insurers are progressively aiming to extend their function past the usual insurance offerings, aiming to deliver a more comprehensive and cohesive approach to healthcare by transforming to:
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“Bridge connectors”, Facilitate the relationship between patients and care providers, using technology to enhance the provider and patient relationship, thus playing an active role in getting consumers the right care.
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Furthermore, Health Insurers, mainly in the USA, have evolved into “Care integrators” by integrating vertically to align incentives, improve care coordination, tackle utilization, and keep medical costs low. They reposition themselves from merely a payer to “connectors” and evolve further into payer-provider.
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Dental insurance coverage is lagging far behind in the transformation journey. As proof, most dental insurance plans are characterized by:
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Low Cover limits
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Substantial protection gaps for major treatments
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In most cases, Insurers remain pure reimbursors, with no relation to care providers
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Manual document-based business processes
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Substandard Data and expertise around Dental Health risks
Dental Care out of Scope
Provider's challenge
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Globally, in the majority of countries, the provision of dental services is still characterized mainly by conventional sole practice.
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Even in advanced markets sole practicing is dominant. In the USA 27% do not single practice, and 11% are affiliated with Dental Support Organizations. In the UK and Spain 25% of dentists are organized in chains, for the rest of the markets the number of dentists per practice location is 1 to 2.
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A scattered provider’s landscape represents a sizeable barrier to establishing a network with preagreed care practices - Protocols and prices. Traditionally insurers set up agreements with healthcare entities like clinics, hospitals, and laboratory centers. Agreements with sole-practicing doctors are established on the grounds of a fixed fee per consultation.
Public Healthcare Systems
co-ordination
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Public healthcare system coverage of dental health is key for the development of private insurance offers as the two operational models can coordinate and Private insurance acts as supplementary for the public one, following the public one’s validation of insured and claim case.
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Most public healthcare systems do not provide coverage for adults.
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Some PHSs provide limited scope coverage under fee for service like NHS Health Insurers are utilizing PHS’s operational model (processes and controls ) in UK. For these markets, Insurers coordinate with Public Healthcare Systems for the validation of (i) the Insured’s ID (ii) the claim case (iii) the service provided, by covering part of the remaining fee up to the contract limit. Health Insurers are utilizing PHS’s operational model (processes and controls).
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In these cases where Dental health coverage is not provided by PHS full claim process (Network of providers, eligibility of insured, claim case validation) has to be managed by Insurance Co’s operating model for dental coverage).
Fraud & Abuse management
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The reimbursement model is exposed to high fraud and abuse risk. The risk has evolved during the last years due to the:
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Increasing demand for cosmetic dentistry
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Increasing demand for dental implants (20% of global Dental Service value)
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The invoiced patient (Insured) may not be the actual patient.
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Invoiced service may not be the actual service. Pathology for cosmetic treatment or multiple charges/services for justification of increased reimbursement.
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Health Insurers provide in-hospital care and laboratory coverage by introducing preapproval processes, partnering networks, and shifting from reimbursement to direct billing models.
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The preapproval process can be a pain point for dental coverage as it would require on spot decision for most cases (even standard and customary).
Risk Knowledge
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As dental is out of the scope of insurers thus there is a globally lack of dental care Knowledge.
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No UW info is gathered vs comprehensive health insurance in general (questionnaire, examinations, etc.).
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Dental records are not usually available.
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Best Claims data are limited to generic service descriptions and cost, in the best case.
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In that sense, no assessment can be safely concluded on Dental Health Status and its expected evolution, only reactive financial assessment.
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Pricing models are highly underdeveloped, and available claims data are limited and underutilized.
Our Industry Partners
COLLABORATION
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The lagging of dental coverage by Health Insurers can be attributed to the combined effect of many parameters:
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Providers (Dentists) Market structure
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The public healthcare system’s coverage of oral health
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Operational efficiency
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Fraud and abuse evolving risk
Our Business Digital Solution
Enables driving and optimizing value creation for all stakeholders, Insurers, Customers, and Dentists, by leveraging Ai over a fully digitalized business model
Efficiency
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High frequency - Low cost
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Dental care is a high-frequency risk (more than 40% % of people visit at least once per year a dentist)
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The majority of cases are standard low-cost services (check-ups, fillings, etc.)
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Managing such risk models over physical documents & manually is highly inefficient contributing to more than 15% of admin charge over the required premium.
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For practicing Dental Insurance, a fully digitalized operating model is required, secured by a developed Fraud and Abuse control implemented framework and, automated preapproval process, at the agreed service cost.
SmAile targets to be the preferred solution partner
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Network Management
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Build and manage local proprietary Dental Networks
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Integrate solutions within an existing contracted network of Insurer or TPA
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Enhance the partner’s network with selected members of the proprietary network
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Customizable at the product/service level
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Network performance KPIs reporting (dental, operational, financial)
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Fraud & abuse Automated Control driven by Ai
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Patient validation
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Diagnosis validation
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Service validation
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Service pricing
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Data Driven Risk Management
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Fully mapped oral health assessment per insured
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Clinical predictions
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Statistical predictions
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Predictive pricing algorithms for Renewals/New sales/new products
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Product modelling
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Fully automated claim process
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First Notification of Loss
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Eligibility control
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Case approval screening (over 90% of common cases)
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Escalation communication
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Reserving
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Claims payment accounts
