Dental insurer takes bite out of fraud

America’s largest dental insurer uses SAS^® to improve patient care while reducing costs

Nobody likes getting their teeth cleaned. But the millions of Americans covered by DentaQuest are enjoying lower costs plus better oral care – all made possible by analytics.

DentaQuest is the largest dental benefits administrator in the United States, and largest in the Medicaid space. With 24 million members, the insurer sought a powerful analytics platform to detect fraud, monitor business performance and comply with guidelines set by the Centers for Medicare & Medicaid Services.

Dean Webb, Senior Manager of Analytics, runs a 12-person team responsible for delivering insight to an organization of nearly 2,000 people. Before acquiring the SAS Platform, Webb says his team was stuck with underpowered tools.

“We started with Microsoft Excel,” Webb says. “However, because of the size and scale of DentaQuest, there was no way we could process millions of records of claims data using those tools.”

The insurer turned to SAS for a data mining and analytics platform. SAS^® Enterprise Miner™ enables Webb’s team to model key metrics and detect fraud. SAS^® Enterprise Guide^® provides capabilities for time series analysis, monitoring client performance, forecasting and simulation of various scenarios.

The addition of powerful analytics technologies supercharged the team’s efficiency. “We went from having no decent tools to going right to SAS, which is a powerhouse,” Webb says. “We use it every single day, and we are two to three times more efficient because of it.”

Reducing fraud while revealing high-quality providers

Insurance fraud costs the US health care industry tens of billions of dollars each year – money that can’t be spent on improving the quality of care.

DentaQuest uses SAS to detect and prevent fraud. Data from claims, providers and other sources are modeled using SAS Enterprise Miner. The technology reviews more than 50 different indicators of potential fraud, waste and abuse in the models to flag suspicious claims. Investigators can then prioritize cases based on severity to tackle the most pressing cases first.

Webb was recently asked by management to score provider performance, with the goal of identifying irresponsible clinicians and improving patient outcomes. “We have some providers that may not be doing the right services at the right time, or are doing too many services,” Webb says. “We want to make sure our dollars are being allocated to more preventive and diagnostic services.”

The scoring model exposed low-quality providers, allowing DentaQuest to move those patients to higher-scoring providers. “SAS enables us to not only reduce costs but also improve quality of care,” says Webb. “Now, instead of using high-cost restorative services, we can shift patients to providers with more beneficial preventive, diagnostic-type services.”

Monitoring business performance

SAS is used extensively to monitor and measure business performance. One key metric tracked by Webb’s team is quality of care, which the Centers for Medicare & Medicaid Services monitors for both DentaQuest and its clients. Targets get tougher every year, and Webb uses SAS to keep his organization compliant.

Geomapping is another particularly useful feature, according to Webb. With customers spanning the United States, Webb’s team uses SAS to aggregate various claim attributes and create metrics across different geographies. This allows the company to benchmark performance by state and share results across the business via dashboards.

“We can run four to five years of claims data – millions and millions of records – and SAS handles that with ease,” says Webb. “Being able to manipulate very large data sets and then dig into the data, dive deeper and analyze it very quickly and effectively is a huge benefit for us.”

The ability to quickly and easily measure performance has made SAS popular in the company’s marketing department. By scrutinizing campaign performance, marketing leaders can direct investment to the highest-performing channels. “That's been a big area of improvement over the past year,” says Webb. “We've had a number of markets where we've seen positive lift by up to 30 percent.”

Taking analytics to the next level

Webb’s relatively small team must operate efficiently to keep pace with organizational demands. While his team has created some repeatable models, Webb says those models could be optimized further. To accomplish this, he encourages his team to continue learning and expanding their knowledge of SAS.

“Everyone on our team is a huge fan of SAS,” says Webb. “It's very user-friendly, but it's super deep as well. We're probably only tapping 20 percent of what SAS can do.”