SCALE Case Study:

Payer Strategy – Dental (DSO)

Client Profile

  • Size:
    43 Clinics
  • Specialty:
    Dental

Services Deployed

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Consulting

Payer Strategy

Financial Analysis

Regulatory Research

Overview

SCALE was engaged by a Dental Services Organization (DSO) participating with a Managed Care Organization (MCO) providing dental services to Medicaid recipients for which a rate reduction was imminent. The engagement included providing financial analyses to quantify service line impact, payer contract review and strategy development to improve their rate position.

  • The Client is a comprehensive provider of dental services in the US operating in Medicaid-focused clinics.
  • The Client has multiple providers who perform oral surgery in addition to pediatric and adult dental hygiene services, setting them apart from other provider groups.
  • They serve a mix of Medicaid and commercial patients with a large population of childrenat 43 clinics across the entire state.

Execution

SCALE Payer Strategy and Consulting business segments conducted a thorough financial analysis
of proposed rate reductions supported by contract review, a regulatory assessment, and research
on the Medicaid network in the state.

SCALE developed a comprehensive strategy to counteract proposed rate cuts:

  • Financial analysis of all clinic locations, revenue, profits, and risk of potential reductions.
  • Contract review of terms regarding rate change notifications, dispute resolution, and termination of contract.
  • Review of the current dental MCO contract.
  • Research on legislative and regulatory requirements e.g., Medicaid funding obligations.
  • Market data on the size of the provider group relative to the entire Medicaid market and network adequacy requirements.
  • SCALE recommended strategic contractual and service line scenarios to improvement to improved rates.
  • Additionally, leveraged stakeholder relationships through multiple meetings to advance to the client’s objectives.
  • Initiated and progressed with prompt payer communication throughout the negotiation process.

Results

As a result of discussions with the MCO, both groups agreed to mutually understandable financial
terms as well as a Memorandum of Understanding to solidify non-contractual terms and strengthen their continued partnership.

  • SCALE quantified potential losses and prevented rate reductions from being implemented as originally proposed by the MCO.
  • Other administrative issues were addressed during the payer-provider negotiation process related to prior authorizations, preferred provider status, and patient panel management.

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