Administration

Utilization Management (UM), and Fraud and Abuse

DentaQuest's approach to UM recognizes differences in practice patterns and ensures that patient costs are in line. We have utilization review mechanisms to monitor trends, patterns of utilization, and the proper delivery of services. We keep a watchful eye on potential fraud. Members receive the medically necessary services covered under managed care organization or state guidelines. This helps prevent under- and over-treatment, and minimizes unnecessary provider billing.

Our goals are to:

• Prevent fraud and abuse,
• Stop fraud and abuse when it occurs,
• Assist in the recovery of losses,
• Help to apprehend and prosecute the perpetrator, and
• Educate employees and members to identify potential problems.

DentaQuest analyzes claims data to identify billing patterns that indicate fraudulent activity. An investigation will determine whether any improper billing charges may have occurred. If one did, a recovery action is initiated. We are committed to helping our clients limit the potential for fraudulent claims.

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