P&R Dental Strategies Refines the Science of State-by-State Compliance

NEW YORK, April 21 /PRNewswire-USNewswire/ -- Talk to anyone in the dental insurance arena about the burdens of bureaucracy and you are sure to get an earful, as each new season brings even more changes to yet more regulations from various states all across the country. The penalty for not adhering strictly to the rules can be steep in both financial and professional terms. With 50 State legislatures in the mix, each answering to the interests of its own constituency, the challenge for P&R Dental Strategies, the industry leader in dental benefits cost containment, is ensuring that they remain alert to the ever-changing landscape, and are vigilant in adhering to the varying degree of rules and requirements from state to state.

It is a complex arena, but one in which Cheryl Eckstein, Compliance Officer for P&R, shines. It is her job to make sure that all of the company's dental benefit payor clients are 100% compliant. "At this moment in time," Mrs. Eckstein notes, "twenty-five states require that review of dental claims be conducted by agents who have been certified by those states. In addition, there are fifteen states in which the dental consultant has to be licensed by its Board of Dental Examiners to review a claim to practice dentistry in that State. There are quite a few additional regulatory demands that vary from state to state, and these rules are evolving all the time."

P&R launched a determined effort to obtain full certification in all the states when UR (utilization or claim review) compliance regulations first appeared. In addition, P&R invested in the identification, training, ongoing monitoring and quality control of dentists who could conduct claim review for those states with home-state licensure requirements. This was no small task and took several years to accomplish, but P&R had made a commitment, and was determined to provide compliant professional claim review in every state of the Union.

"Of course," Mrs. Eckstein said, "certification, alone, is just the tip of the iceberg when it comes to complying with state regulations." She notes that other requirements, which vary from state-to-state and continue to change, include:

• Notification of claim decisions in writing and/or by phone to administrators, providers and insurers within varying state-mandated timeframes,
• State-by-state mandated notification letter format must be used for certain jurisdictions, and sometimes even different formats, based on the level of review,
• Mandated annual reports to Insurance Commissioners,
• Different mandated timeframes for completed review of prospective and retrospective claims, as well as for appeals,
• State mandated phone calls to providers prior to making an adverse claim decision,
• State mandated specialist review for appeals of specialty of provider claims, and
• State mandated external appeal protocols for adverse decision claims.

With her finger on the pulse of insurance regulation in each State, and a system in place to ensure that she is notified of any upcoming changes that may occur, Mrs. Eckstein is well positioned to oversee state-by-state compliance activities for P&R, but she also has a huge advantage at her fingertips: the proprietary P&R Claim Review Management System (CRMS).  Designed to provide instant information on the status of a dental insurance claim, quick flow of the claim through the process, and thorough evaluation of the claim's merit, the system also automatically generates those letters and notification documents required by state agencies.

All completed reviews generate appropriate compliance letters on a daily basis at the P&R office, from which they are mailed according to state mandates. In addition, any phone call notifications required by law are scheduled by the program and made daily. All these activities are then logged and documented in the system to establish an audit trail.

"The CRMS makes my job easier," Mrs. Eckstein said, "and having it at our disposal ensures that we are able to generate a real return on investment for our payor clients."

For more information about the science of State-by-State compliance as applied by P&R Dental Strategies, Inc., please visit the website at pandrdental.com, or contact George Thomas Wilson at 917 716-4205 or [email protected].

SOURCE P&R Dental Strategies, Inc.