Our complete utilization management program evaluates the appropriateness, need for treatment and efficiency of dental services, procedures and facilities according to the established guidelines of our clients health plans.

At Hemisferica we provide our clients with forward and backward looking utilization review and management services. By analyzing provider and claims history in our claims repository, we provide health plans with the tools necessary to effectively manage their provider networks. At the same time, our team helps clients save money by monitoring and identifying fraudulent utilization patterns.

A strong Utilization Management program is a necessary and effective network management strategy.

Preferred Provider Organization (PPO) networks are based on discounted fees. Even though providers agree to discounted fees some might attempt to make up for the discount by increasing the utilization of their services, which is the amount and frequency of treatment recommended or the recommendation of more expensive procedures. Such over-utilization or “up-coding” is detrimental for the patient, the employer and the health benefits plan or insurance carrier.

Employers and benefit consultants quickly point to the two important factors that determine total claim cost:

Overall Claim Cost = (Utilization x Provider Fee) + Processing Cost

At Hemisferica we help our clients manage both sides of the equation. We lower overall claims cost by managing utilization and by lowering the cost of claims processing.