Pronto designed to stop dental insurance fraud

Feb 17, 2010

P&R Dental Strategies has introduced Pronto, a dental insurance fraud detection product designed to maximize return-on-investment of utilization review. Rather than just review any claim based on standard referral guidelines, Pronto identifies the appropriate mix of providers and procedures that will yield the greatest savings, according to the company.

"Our mission is to save our clients as much money as possible without sacrificing quality of patient care," said Dianne Rose, D.D.S., co-founder of P&R Dental Strategies, in a press release. "Cost containment has always been our primary purpose, and now, with Pronto, we are able to take the services we provide to an entirely new level."

Traditional industry claim review services rely on dental payors identifying a static list of services it believes are potentially fraudulent and abusive. Payors then route the claims with those services to reviewers who determine whether the service is medically necessary.

Pronto algorithms are derived from a large cross-payor database that includes utilization data on almost every dental service provider in the U.S., Dr. Rose explained. This data is then analyzed, using proprietary algorithms, in real time by Pronto, to identify those providers and procedures that may yield significant savings due to the unnecessary nature of those services.

"When we started, we were building upon the systems the insurance companies already had in place, but through creative mining of data and trends, were able to do it more efficiently and cost-effectively than our clients," Dr. Rose said. "But through the years, with our growing understanding of the industry and deepening knowledge of how best to accomplish our job, we have been able to deliver ever more return on our clients' investment in us. And, now we can focus on those claims and providers most likely to exhibit aberrant billing practices."

According to the National Health Care Anti-Fraud Association, the most common medical fraudulent activities are billing for services/procedures/supplies that were never delivered, intentional misrepresentation of treatment or services provided to obtain a greater payment than that to which the provider is entitled to receive, and the deliberate performance of unnecessary procedures for financial gain.