Better Eligibility and Benefits Results Give Regence Dental Providers Something to Smile About 

Regence and Availity enhanced eligibility and benefit results for dental providers, improving the experience and reducing support phone calls. 

Problem 

 After launching its dental eligibility and benefits service through Availity’s Provider Engagement Portal (Now known as Availity Essentials), Regence did not see the expected decrease in call center volume, suggesting that dental providers weren’t getting the level of information they needed. Before a patient comes in, dental providers fill out a pre-service form to understand annual limits on x-rays and cleanings, as well as multi-year limits on services such as crowns. “Providers were able to get basic benefit information [from Availity],” said Richard Smith, a provider operations product owner at Regence. “But if they couldn’t find something specific, they would just call the call center.” Inevitably, providers were losing confidence in Availity and relying more on the phone 

To better understand what was behind the dissatisfaction, Regence used call center information, provider surveys, and usability sessions to uncover core issues with benefit information in Availity Workflows:  

• Providers felt the data was incomplete. 
• The layout of data on the screen made information difficult to find. 
• Providers had to scroll through multiple pages of information. 
• Providers were not able to access multi-year accumulator information. 
• Providers, at times, were unsure which benefit service type to select to obtain the correct benefit details.  

Solution  

After evaluating provider feedback, Regence and Availity needed to solve two different challenges: how to deliver the level of detail that the dental providers were looking for and how to display the information in a way that was easy for them to consume. 

Leveraging procedure codes  

Regence and Availity determined that the best way to deliver more granular information would be to allow providers to check benefits at the procedure code level, in addition to the service type code (STC) level. Whereas the STC could indicate “crown,” the procedure code-level benefit information could indicate whether it was a new crown, replacement, porcelain, Which tooth, etc. Procedure code level lookup also enables users to view multi-year accumulation limits for applicable benefit types. 

 Adding to the complexity for dental, the ANSI ASC x12 271 version 5010 does not specify the standards for transmitting tooth information, so Availity worked with Regence to establish a consistent transmission set that other payers could also use and wouldn’t conflict with existing dental standards.  

“Regence had never provided benefit detail at the procedure code level before,” said Smith. “It was a significant effort on our end, and we could see the longer-term potential for using the solution for medical procedure codes.”  

Optimizing the user experience  

Tackling the usability issue, Availity underwent a rigorous and multi-faceted user experience redesign. In addition to the feedback from Regence’s usability sessions, Availity conducted surveys, focus groups, and onsite visits. A concise, tabular view was created from the analysis, aligning with how dental providers read the benefits. Before writing any code, Availity mocked up designs and got feedback from users.  

“Availity’s responsibility is to make payer information easy for providers to access and to understand,” said Tom Mort, a pre-service product owner at Availity. “Payers can provide robust detail in the EDI transaction, and Availity will display the information in simple, clear language, giving the provider confidence in the data and reducing calls.” 

Results  

Regence launched the enhanced dental benefits user interface in October of 2020—just as many restrictions lifted from Covid-19 and dental appointments resumed. Given this timing, and some slight annual increases in dental membership and dental providers, Regence wanted to conduct extensive call-volume analysis to establish an accurate baseline for evaluating ROI.

“After factoring in many of the unique variables of the last year, we determined that the new user interface reduced dental provider calls by 11%,” said Smith. At the current rate, he anticipates monthly call volume to decrease by approximately 2% each month. “In just eight months, we’ve seen $75,000 in call-volume savings, which we expect to increase as data normalizes.”

Considering the non-standard call volume, Smith has been impressed with the early results. “Delivering eligibility results at the procedure code level gave providers much more trust in the information, and the revised design also made a huge difference.” He noted that the call volume analysis didn’t include provider satisfaction, which was also a key benefit of the project.

Smith believes Regence can see similar call-volume improvements by implementing procedure codes in medical benefits. “Every dental and some medical plans have multi-year accumulators. Having gone through this work with dental, a lot of the medical pieces fall into place easier. The successful launch of our dental benefit enhancements has us excited to begin exploring similar functionality for medical services.”