How Naviquis helped a regional health plan prevent $12.4M in losses across medical and dental networks
- 2.4M members
- 33.4M claims analyzed across medical and dental
- $12.4M improper payments prevented
- 3 multi-line fraud rings dismantled
- 44 high-risk providers flagged
- 29 days to full cross-line visibility
The Challenge
A regional integrated health plan noticed rising costs in both outpatient medical services and pediatric dental claims. Medical and Dental departments worked in silos, each using a separate payment integrity vendor, and neither could analyze claims across the other line of business.
That gap is exactly what fraudsters exploited: medical sedation billed alongside same-day dental restorations, dental X-rays that resembled radiographs already billed under medical oral surgery claims, and providers credentialed in one line of business but unlicensed in another. The plan’s legacy vendor was blunt about the limitation: they did not cross-analyze medical and dental claims.
Without unified analytics, computer vision for imaging, and cross-line credentialing checks, the fraud was invisible, split cleanly down the seam between two systems that never talked to each other.
The Naviquis Solution
Naviquis deployed its unified Medical and Dental Payment Integrity Engine, combining cross-line risk scoring, X-ray computer vision, medical necessity and CDT clinical logic, duplicate detection across both claim types, and provider credentialing and sanction cross-analysis. Within 29 days, the health plan had complete visibility across both lines of business for the first time.
Three Crossover Fraud Rings Uncovered
None of these patterns would have surfaced under separate medical and dental review. Each depended on seeing both sides of the claim at once.
Ring 1: The Sedation-to-Crown Pipeline
Pattern: Urgent care centers billed medical sedation for an emergency clearance, then routed members same-day to partner dental clinics for multiple stainless-steel crowns and pulpotomies.
How it was caught: Sedation codes matched dental procedure sequences within 60 minutes, dental X-rays matched medical radiographs, clinical rules showed no necessity for full-mouth restorations, and two providers had revoked licenses.
Result: $5.8M prevented, 2 medical centers terminated, 3 dentists removed, and 1 state-level probe opened.
Ring 2: The Dual-Billing Oral Surgery Network
Pattern: An oral surgery group billed overlapping procedures to both medical and dental using the same supporting documentation for each.
How it was caught: NLP found about 92% text similarity between operative notes submitted months apart, computer vision matched surgical photos reused across both claim types, and one surgeon had no active privileges.
Result: $3.2M prevented, 1,108 claims blocked pre-payment, and 5 providers referred for investigation.
Ring 3: The Pediatric Preventive Abuse Loop
Pattern: A mobile pediatric dental group billed sealants and fluoride to Dental while billing oral health risk assessments and supplies to Medical for the same children during school visits.
How it was caught: Duplicate member-service pairs across both systems, identical X-rays reused across multiple children, CDT codes inconsistent with patient age, and copy-pasted progress notes.
Result: $3.4M prevented, 2,420 invalid lines flagged, and 1,100+ duplicated services caught.
The ROI: First 90 Days
| Metric | Value |
|---|---|
| Fraud prevented | $12.4M |
| Crossover fraud rings disrupted | 3 |
| Duplicate medical and dental claims flagged | 413,000+ |
| Invalid CDT/CPT combinations | 58,700+ |
| Unnecessary pediatric procedures caught | 2,800+ |
| High-risk providers flagged | 44 |
| Credentialing gaps detected | 18 |
| Member safety incidents avoided | 200+ |
| Provider abrasion | Down 51% |
| Clean claim rate | Up 19% |
The plan achieved a 7:1 ROI within six months.
What Changed
- Medical and Dental payment integrity became unified for the first time, closing the gap fraud rings had exploited for years
- Real-time, pre-payment prevention replaced delayed clawbacks, with 95%+ of improper crossover payments stopped before reimbursement
- Imaging AI audited X-rays, radiographs, and surgical photos in seconds instead of leaving them unchecked
- Credentialing became a frontline fraud-prevention tool, catching cross-state sanctions early
- Transparent, real-time provider communication cut abrasion by 51% while still enforcing controls
- Unnecessary and potentially harmful procedures on children were prevented before they happened
We had no idea Medical and Dental fraud rings were coordinated. Naviquis connected dots that nobody else in our organization, or our vendors, could see.
Chief Compliance Officer, Regional Integrated Health Plan
Conclusion
Medical and Dental fraud hides in the gap between separate systems, siloed vendors, and inconsistent credentialing. Naviquis closes that gap, stopping fraud before disbursement, protecting members, and dismantling multi-line fraud rings that no single-line vendor can see.
What crossover fraud is hiding in your claims right now?
Request a Medical and Dental Crossover Integrity Assessment and talk to the Naviquis Payment Integrity team.