How Accreditation Makes a Dental Plan Stand Out

By Carole Crawford, RN, URAC Accreditation Reviewer on Aug 8, 2017 4:00:00 AM

Dental plans seeking to widen their provider network while providing an exceptional member experience can differentiate themselves through accreditation. It provides an objective, external review of the quality, security, safety and fairness of their operations and assures providers and members alike that the plan adheres to industry best practices in all areas. But that’s just the beginning.

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URAC’s Dental Plan Accreditation standards also emphasize consumer protection and patient safety to ensure that members truly have a superior experience. For example, dental plans must have procedures that spell out how the organization will respond to urgent situations that pose an immediate risk to the health and safety of consumers. Some plans even practice their ability to respond quickly by conducting mock phone calls from “members” who disclose child, spouse or elder abuse. These drill exercises are then reviewed at a staff meeting.

Another URAC standard requires dental plans to have at least one quality improvement project that focuses on a known consumer safety issue. Some plans identify these issues by surveying staff for input.

When it comes to appeals, URAC’s standards require organizations to base denial decisions on current clinical practice guidelines and clinical review criteria. In addition, URAC standards require the provider who conducts the appeal to practice in the same specialty as the provider who would typically manage the member’s medical condition, procedure or treatment. In practical terms, that means that a provider reviewing a coverage denial for maxillofacial surgery must be a maxillofacial surgeon.

Of course, the dental plan also benefits by URAC Dental Plan Accreditation. URAC’s standards provide a framework that helps dental plans identify operational changes that can save money, streamline quality management and improve regulatory compliance.  

For example, an organization must develop action plans for everything from quality management program objectives and resources to who will serve on the quality management committee and what projects they’ll undertake. In fact, dental plans that achieve the URAC Accreditation Seal often tell us how URAC’s standards have helped them become a leaner, smarter and more effective organization.

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Topics: Dental Plans

Carole Crawford, RN, URAC Accreditation Reviewer

Written by Carole Crawford, RN, URAC Accreditation Reviewer

Carole Crawford has been a full time accreditation reviewer with URAC for eight years, most recently as lead reviewer for Health Plan and Health Insurance Marketplace accreditations. Prior to joining URAC, she spent 15 years working for a large national health plan with responsibilities for accreditation activities in utilization management, network management, credentialing, quality, HEDIS, data submission, and claims. In 1996 she achieved Certification as a Professional in Health Care Quality (CPHQ). In addition, she worked for an IPA (independent physician organization) wearing many hats and has more than 25 years of clinical nursing in the acute care setting.

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