September 14, 2022

How to optimize dental utilization review efficiency with artificial intelligence technology and predictive analytics

optimizing utilization review workflow with AI and dental consultants image

Evolving utilization review processes to the next level requires harnessing the power of both predictive analytics and artificial intelligence image review technology.

Interest in the use of artificial intelligence technology in the dental industry has been growing steadily, with many practices considering the use of A.I. for additional clinical support. A.I. can streamline processes and enhance workflow and see things even a trained eye can miss. A.I. has even been successfully used to diagnose patients, with experts noting that it has the potential to reduce provider fatigue and diagnostic errors.

Outside of the dental office, payers are beginning to glimpse the potential for improving the claim selection process with the use of A.I. technology and machine learning (ML).

The challenge of integrating A.I. into the business

As many payers discover when piloting A.I. technology in their utilization review process, obtaining X-rays and other images to support a robust A.I.-powered image analysis process poses several unique challenges including:

  • It can be quite disruptive to existing dental office behavior patterns: any A.I.-powered image analysis will require the dentist to supply either high-quality image copies or to provide access to its digital image files.
  • The actual number of claims by volume where images are expected in the clinical review process is quite small, limiting the overall utility and applicability of A.I.-powered image analysis in dental claim review.
  • A high percentage of x-ray images that arrive with a claim at submission will be of insufficient clinical quality or represent something other than the relevant radiograph or digital image. Photocopies or scans of images continue to be a normal submission for many dentists.

It is possible to overcome these challenges and the growing expense that comes with them, however. When artificial intelligence image review technology is combined with an algorithmically-driven, predictive analytics engine that does not rely on processing images to determine which claims should be reviewed, real efficiency and flexibility are unlocked. This synergistic combination of image-independent predictive analytics and A.I. image technology allows dental payers to experience the future of managing a utilization review workflow: smart selection of which claims to review.

A predictive analytics engine to efficiently manage UR workflow

An inefficient dental claim review workflow can eat up internal resources, introduce delays and create backlogs. Reviewing every claim or auto-adjudicating every claim — extreme opposite ends of the review philosophy spectrum — only compounds issues and costs. One solution is for payers to utilize a pre-payment predictive analytics engine in their claim review process. With advanced algorithms, pattern recognition tools and a sufficiently large database of procedure records from multiple payers to analyze, such a “smart claim selection” platform would work with or without x-rays and be able to predict, in real time, which dental claims are most likely to result in a denial due to insufficient medical necessity or inappropriate billing practices. This approach has many potential benefits:

  • Spotting outliers with the predictive analytics engine before payment actively protects the value of member benefits.
  • Makes claim review resources available to deploy to the claims that represent the best opportunity for savings.
  • Increases provider satisfaction by rewarding providers who practice within statistical norms with fewer time-consuming reviews.
  • Eliminates cycles of “pay and chase” that drain an organization’s time.

Enhancing a predictive analytics engine with artificial intelligence image review technology: A complete plan

On its own, a predictive analytics engine is an extremely powerful tool to enhance the efficiency of the utilization review process. However, by combining it with A.I. image analysis technology, a true “smart claim selection” workflow can be attained. Here are three key components of a complete smart claim selection plan:

  1. A rules-based, pattern recognition predictive analytics engine to evaluate all of a payer’s daily claims volume in real time, rank ordering the claims that have the highest probability of generating savings for review (with or without images)
  2. A.I. image analysis software working in parallel with the predictive engine, determining if an available image meets clinical guidelines and is sufficient for evaluation
  3. Dental consultants to review the claim if the predictive analytics engine and/or the A.I. image software determines that further review is required

The third component of this “three-legged stool” is critical. A licensed dentist is still required in the process if a claim is to be denied or partially denied: payers must still retain dental consultants on staff, or outsource their claim review. The human, dental consultant element is also an added benefit when they are used to support calibration of the system and A.I./machine learning processes.

Digital processes empower better patient care and business efficiency

From diagnostic assistance to streamlining the patient check-in process, A.I. is beginning to revolutionize the oral healthcare industry. Experts agree that embracing digital workflows and the increase of digitalization can not only improve the doctor-patient relationship, with providers able to spend more time communicating with patients rather than being bogged down by back-office administrative tasks, but it can also lead to more evidence-based decisions. Likewise, dental insurers also stand to benefit greatly in efficiency and cost savings by implementing A.I. technology into their utilization review processes — either by taking the time to develop the technology themselves or by choosing a trusted partner with the data, a legacy of utilization review expertise and smart claim selection platform to do it for them.

To learn more about how optimize dental utilization review efficiency by combining predictive analytics, artificial intelligence image technology and the expertise of dental consultants, contact P&R Dental Strategies today.