2020 vision looking ahead to the next decade in ......pnr learning summit 2019 presentation...

Confidential and Proprietary

The Authority on Dental Quality®

Learning & Informatics Summit

2019

©2019 P&R Dental Strategies, LLC – Confidential and Proprietary

June 26th – 27th 2019 • The Thompson, Chicago

2020 VISION: LOOKING AHEADTO THE NEXT DECADE IN DENTALJune 27th, 2019




2019

©2019 P&R Dental Strategies, LLC – Confidential and Proprietary

June 26th – 27th 2019 • The Thompson, Chicago

SESSION 2 ABSTRACT:FIGHTING FRAUD 101Equip Your Team with Advanced Data Tools to Combat Outlier Abuse




2019Learning & Informatics Summit

2019

Fraud, Waste, & Abuse Trends




2019

Profiling in Dental

• Identification of behaviors outside the norm across a variety of metrics

• Over 400 standard ratios are the foundation of profiling• Statistical evaluation based on outliers both above

and below the norm

4




2019

Statistical Profiling Trends

Key areas of outlier behavior are in the following areas:

Over-utilization of Non-Surgical

Extractions

Up-coding of Surgical

Extractions

Over-utilization /

Up-coding of Amalgam & Composite Surfaces

Over-utilization of

Crowns

Over-utilization of

Occlusal Guards

Over-utilization of Scaling &

Root Planing (Under and

Over age 30)

Over-utilization of Bone

Replacement Grafts

2016

-20

17

Over-utilization of Non-Surgical

Extractions

Up-coding of Surgical

Extractions

Over-utilization /

Up-coding of Amalgam & Composite Surfaces

Over-utilization of

Crowns

Over-utilization of Scaling &

Root Planing (Under and

Over age 30)


Replacement Grafts

2017

-20

18

Up-coding of Impactions

Over-utilization /Up-coding of Amalgam & Composite Surfaces

Over-utilization of Crowns

Over-utilization of Pins

Over—utilization,

Unbundling, & Upcoding

of D4346


Replacement Grafts,

GTR & Tissue Grafts

Overutilization of Surgical Removal of Residual

Roots, I&D, Biopsies

Unbundling of gingivectomy

and crown lengthening

2018

-20

19





2019

Observed trends in clinical review continue to show a number of problem areas resulting in fraud and/or abuse alerts and confirming profiling concerns

Clinical Review Trends

Gross Upcoding of Extractions

Over-coding of restorative

fillings

Use of standard narratives

Does not support the treatment

Does not show billed care was performed

Changing Perio

Charts

Changing Procedure

CodesChanging Narratives

2016

-20

17

Upcoding Documentation Does Not Support

Changed Documentation



fillings

Build-ups on Virgin

Teeth




Changing Perio

Charts

Changing Procedure


2017

-20

18



fillings

Build-ups on Virgin

Teeth




Changing Perio

Charts

Changing Procedure


2018

-20

19





2019

Year-over-Year Change – Outlier Ratios

Unbundling

5%IncreaseO

VER

ALL

Upcoding11% of the ratios monitored 15% of the ratios monitored 74% of the ratios monitored

Over-Utilization

Single, 2, 3, & 4 Surface Direct Restorations

Crowns, Onlays, Prefab Crowns, Veneers

Indirect/Direct Pulp Caps, RCT Retreats & Apicoectomies

Limited & Comprehensive Problem-Focused Exams, Office visits after hours & for observation only

Imaging – Bitewings, Periapicals

Impactions, I&D, Surgical Removal of Roots, Bone Grafts, Tissue Grafts, GTR

4346, Unspecified procedures

Unbundling Gingivectomies

Unbundling Crown Lengthening

Unbundling Problem Focused Exams

Unbundling Pulpoptomies w/ RCT

Unbundling other X-rays with Full Mouth Series

Unbundling 4346 with other Perioprocedures

Upcoding Impactions

Upcoding 2, 3 & 4 Surface Direct Restorations

Upcoding Extensive Problem Focused Exams

Upcoding I&D

Upcoding 4346

+5% Increase -5% Decrease +11% Increase





2019

Core Build Ups: The Case for Review by Dental Consultants

Scenario

When processors approve based on guidelines

Core Build Up: The tooth is fractured off horizontally with little tooth structure remaining.

(Processor allows, but biologic width may not be adequate)




2019

Core Build Ups

Lack of Response for Information

Denied/ No demonstrated

Necessity12% 88%

Over 150,000 core build ups were not resubmitted following initial necessity review denial.

Common Processes for these Codes

Food for Thought

How many unnecessary or inappropriate core build ups are just routinely submitted anticipating auto-adjudication?

Only23% were

resubmitted for reconsideration




2019

LEAT Administration: The Case for Review by Dental Consultants

When processors approve based on guidelines

Scenario 1 Fixed Bridge – No other teeth missing in the arch.(Processor allows, but there may be hopeless teeth also in need of extraction in the same arch, or the abutment crowns may be periodontally unstable on the reviewed bridge)

Scenario 2 Implants- No other teeth missing.(Processor allows, but teeth on both sides of the implant space need crowns on their own merit and a fixed bridge would be adequate)





2019

Pins

Pins are a very low volume procedure. The increasing number of outliers appears across all states – with the largest volume change in Nebraska, Wyoming, and Kansas. The increasing number of outlier providers indicates a potential change in the norm.

Common Processes for these Codes

Low Frequency/ Rare Events

When the norm is zero, a low number of events results in outlier identification. P&R is evaluating low frequency/rare events for refinement in outlier identification.





2019

Payer Level Outlier Scoring




2019

CA Payer-Level vs. DentaBase® Outlier Ratios –One Surface Posterior Composites per Patient

NAT

ION

AL






2019

Practice Level Outlier Scoring




2019

Discovery and Final Methodology

Method 2Create practice-level ratios/measures from

weighted averages of the provider-level

ratios/measuresAll providers at the location

Method 1Calculate ratios/measures at the practice –level by

specialty, with the practice/specialty level

normsSame method as Provider Level

Profiling

Method 3Create practice-level ratios/measures from

weighted averages of the provider-level

ratios/measuresGPs/PDs only in Location

Method 1 is the defined methodology





2019

Chair Hour Calculations




2019

Measure Enhancements – Chair Hours

• P&R is currently in the process of developing standardized chair hour values for all CDT procedures

• These measures will be validated against treatment submissions viewed in DentaBase®

• Once chair hour values are validated, research will be conducted into utilizing chair hours to identify over-billing, fraud, etc.




2019

Example 1 – Relative Time Units for a Day

Average Chair Hours per Day

28

Single Location Practice: The office is

confirmed to have only one practicing/treating dentist at the location

11.6Exams, Direct Restorations,

Stainless Steel Crowns, Pulpotomies, Extractions

14.6X-rays, Prophys, Fluoride, Nutritional Counseling,

Non-IV Sedation

Date of Service March 11

49.2

33.6X-rays, Prophys, Fluoride, Nutritional Counseling,

Sealants, Non-IV Sedation

15.6Exams, Direct Restorations,

Stainless Steel Crowns, Pulpotomies, Extractions

Date of Service March 21

26.2

12.9 Std Devsfrom the Norm





2019

Enhancing your FWA Detection Program




2019

Fraud Detection Service: Back-End Monitoring

Fraud Detection Service

A monitoring and alert service for FWA activities/areas of potential concern

P&R produces and analyzes monthly analytics and forwards alerts/referrals for any suspicious behaviors requiring further investigation for potential FWA




2019

How Does It Work:

DentaBase®Dental Consultant

Alerts

Aggregated Total Billings by NPI and Location

Outlier Volume by NPI and Location

Unrealistic Chair Hours by NPI or

Location

Observed Altered Documentation

Observed Billings for Unnecessary

Care

Observed Documentation Discrepancies

Discrepant provider/location

relationships

% of patients with treatments meeting or

exceeding CYM

Changes in Patterns

P&R Team Reviews Alerts

Qualified Referrals Upon Identification




2019

Example Case 1 – General Practice Specialty





2019

For more information

[email protected]

Thank You!

2020 vision looking ahead to the next decade in ......pnr learning summit 2019 presentation...

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