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Become a high-performing Medicaid Dental program by keeping your focus on lower benefit costs

Focus more on your benefit costs and less on your administrative fees

By John Schaak 

SKYGENUSA Powering Healthcare for the Digital Age


Whenever the talk turns to cutting Medicaid dental costs, the focus is often on reducing administrative fees. Yet while it is important to keep administrative fees low, they represent only about 5% of any program’s total cost. The biggest opportunity to bend the cost curve lies in the other 95%, i.e., the actual benefit costs. This is where the highest-performing Medicaid dental programs are focused — saving a few dollars, instead of a few pennies, per member per month.

Reducing benefit costs requires two things: a sophisticated claims processing system, as well as the expertise necessary to effectively manage a Medicaid dental insurance program.

The right technology can save millions of dollars by itself. Scion Dental uses the Enterprise System (developed by Wonderbox Technologies), which was built as a dental system from the ground up and utilizes state-of-the-art technology to review claims automatically. Simply switching to this technology often yields substantial savings for our clients. In one such recent example, we lowered our client’s benefit costs by more than $3.00 per member per month (pmpm).

In addition to having the right technology, it is critical to have the expertise needed to effectively manage Medicaid benefits.

Scion Dental knows how to analyze and tackle each market. Our team of experts knows what data to gather, how to gather it, and how to analyze it in order to identify the biggest and best opportunities to lower dental spend. Their job is made easier by the fact that many of the tools they use are built right into the Enterprise System. In addition to being able to determine which dentists are providing the most appropriate and efficient care, the reporting tools within the Enterprise System can compare providers on any number of metrics, within any specialty, and within any region.    

Having analyzed each market, our team develops the right strategy for controlling costs. 

This is always a multi-faceted approach that includes, among other things, identifying those dentists who are providing appropriate and efficient care, as well as those who are not. The advanced data analytics employed by our team can identify those dentists who are driving costs up by providing too much care (intentionally or not), as well as those dentists who may even be providing too little care.  Moreover, and regardless of the cost involved, our team is always diligent when it comes to identifying and addressing any cases that may involve pediatric dental abuse.

The next step is to effectively address those providers who are outliers. Doing so requires not only having the right a quiver full of arrows, but also knowing which to use and when. Depending on the case, the options can include, among other things, a letter stating the dentist is outside the norm and being monitored, outreach and education, chart audits, and additional authorization requirements.  

In many cases, one of the most effective tools is a creative reimbursement strategy. Sometimes this means changing the fee that is paid for one or more codes. At Scion Dental, however, this can also mean a more fundamental change to the way in which a dentist is reimbursed.  For example, if a provider is typically receiving 5 or 10 times the amount the average dentist is receiving for a particular code — because of overtreatment — Scion Dental can simply pay the outlying dentist a fixed amount for that code each month. The amount can be the same as what the average dentists are receiving, or some multiple of that amount. This is possible because of the flexibility of the Enterprise System, and it is why Scion Dental speaks in terms of “value-based reimbursement schedules” instead of fee schedules.

The specifics of the strategy may vary, but each is designed to remove the incentive to overtreat or otherwise abuse patients. 

Thus, efficient administration is important, but it’s only a small piece of the puzzle. Focus on reducing dental benefit costs and you’ll see a far greater return on your investment. More importantly, your plan also will have safer, happier, and healthier members.   

When you’re looking to reduce costs, where do you focus — on the administration or benefits? What methods have you implemented to reduce costs? Has preventing FWA been a top priority for your organization?  Leave your thoughts in the comments below.

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Chief Operating Officer John Schaak and his team are responsible for driving growth, operational performance, and customer satisfaction across SKYGEN USA’s suite of solutions. He leads efforts to improve effectiveness and efficiencies in the company’s benefits administration solutions, advance business services including client implementations, and increase customer responsiveness, all of which make it easier for clients to do business with SKYGEN USA as their strategic solutions partner.

Mr. Schaak brings extensive leadership experience in business as well as child advocacy. Prior to joining SKYGEN USA, Mr. Schaak was a Partner with the national law firm Quarles & Brady. An experienced presenter, he most recently addressed the American Academy of Pediatric Dentistry’s Annual Conference on how payers’ care delivery and provider satisfaction can be improved by using technology to identify and recognize high performers.

Mr. Schaak has been listed on the Wisconsin Super Lawyers, Rising Stars list multiple times. He holds a Juris Doctorate from Marquette University Law School. He earned a Bachelor of Science Degree in Political Science and Criminal Justice with a minor in Sociology from the University of Wisconsin Oshkosh.

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