More health insurance payers are adding dental coverage to their product mix. One report says about 80% of health insurers offer dental plans currently, and of those, almost half cover adult dental services. Particularly in this era of whole-person care, adding dental coverage seems like a natural extension of medical coverage. Teeth and gums can reveal early signs of health issues in other parts of the body, while poor dental care can lead to bacterial infections and other health problems.
When adding dental coverage, payers can take a similarly systemic view to ensure these services complement their existing services and provide members and providers with great experiences. To accomplish this goal, payers need to think about the impact of dental coverage on their systems, operations and members, now and in the long term.
To create intelligent, seamless experiences for members across medical and dental services, payers need to consider how dental administrative systems will mesh with core medical administrative systems. How will the two work in concert to create one utilization record for a member? If the dental benefits are built into a major medical plan, is it possible to easily track and calculate the accumulated deductible? Will dental data be available to other providers or to AI-based care management systems to detect possible health problems such as diabetes or cardiac conditions? More prosaically, will employees need to be trained on two different systems?
Taking a Holistic Approach
If payers are running open, modular and extensible core platforms, those qualities should help them address these issues. Systems using REST-based application programming interfaces (APIs) easily integrate with other systems in predictable ways, minimizing operational surprises. By using RESTful APIs, vendors can expose data and functionality of core systems to other systems, such as a dental application.
Some core administrative systems may incorporate a dental module that simply needs to be activated to support a payer’s move into dental coverage. One advantage here is that employees will require less training because they’re already familiar with the system’s look-and-feel and general features. That said, dental modules on core administrative systems need to support the processes and language unique to dental claims administration, such as tooth reference charts and proper dental cavity designations. Recurring scheduled services, such as for orthodontia, should be largely automated. Dental modules should also support coordination of member benefits, calculate out-of-pocket costs upfront, and provide detailed explanations of benefits and administrate incentive programs rewarding members for specific actions.
Better Experience, Better Outcomes
A critical objective throughout should be providing great member experiences. One of our clients migrated its dental business from a legacy system to its existing Facets core administration platform by implementing a new dental module. Because dental and medical membership are now collocated on one system, the insurer says it has successfully integrated membership enrollment across medical and dental products and incorporated both into a single premium bill. That’s a convenience to members that improves plan efficiency.
By seamlessly knitting together medical and dental experiences, insurers can improve care. Consumers who come to payers initially for dental coverage are potential candidates for health plan products such as Medicare Advantage. To personalize care management for these members, dental applications or modules must share member data with core administrative systems to build a complete utilization picture for the health payer to draw on, especially when these members age into government-based managed care plans.
Additionally, AI agents can identify and alert caregivers to warning signs of health issues that are related to dental health. For instance, diabetes can cause dental issues, and some research also indicates periodontal disease can raise blood sugar and potentially lead to diabetes. Through AI analytics, and the merging of medical and dental claims data in a single system of record, caregivers can be alerted to these relationships more quickly.
Offering dental coverage enables payers to diversify services and build relationships with new consumers they might not reach through employer channels. As with good dental care, taking “preventive” care now to ensure dental processing supports long-term goals, will make all the difference in the health of payers’ dental offerings.
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