Dental insurer takes bite out of fraud
SAS helps DentaQuest properly allocate funds and improve patient outcomes.
members rely on DentaQuest for effective and affordable oral health care
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.
SAS enables us to not only reduce costs but also improve quality of care. Now, instead of using high-cost restorative services, we can shift patients to providers with more beneficial preventive, diagnostic-type services. Dean Webb Senior Manager of Analytics DentaQuest
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.”
DentaQuest – Facts & Figures
Tens of billions
Annual cost of insurance fraud in the US health care industry
Different indicators of fraud, waste and abuse are reviewed in SAS to flag suspicious claims
Positive lift from more effective marketing campaigns
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.”
본 문서에 나오는 결과는 본 문서에 설명된 특정 상황, 비즈니스 모델, 데이터 입력 및 컴퓨팅 환경에 적합하게 되어 있습니다. 각 SAS 고객의 경험은 고유한 것으로, 비즈니스 및 기술적 변수에 따라 달라집니다. 따라서 모든 서술은 비전형적인 것이라는 점을 고려해야 합니다. 실제 절약, 결과 및 성능 특성은 개별 고객의 구성 및 조건에 따라 달라질 수 있습니다. SAS는 모든 고객이 비슷한 결과를 달성할 수 있다고 보증하거나 진술하지 않습니다. SAS 제품과 서비스에 대한 유일한 보증은 해당 제품 및 서비스에 대한 서면 계약의 보증서에 명시되어 있습니다. 본 문서의 어떠한 내용도 추가 보증을 구성하는 것으로 해석될 수 없습니다. 고객은 SAS 소프트웨어의 성공적인 구현에 따라 합의된 계약적 교환 또는 프로젝트 성공 요약의 일환으로 성공 사례를 SAS와 공유했습니다. 브랜드 및 제품 명칭은 각 기업의 상표입니다.