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It's that time of year: Are you prepared to be audited by a dental benefit plan?

CDA's dental benefits analyst explains the post-pay audit

July 26, 2021 1561

Quick Summary:

An overlooked portion of a dental benefit plan contract is the plan’s ability to conduct an in-office and/or chart record audit. CDA's dental benefits analyst explains the post-pay audit, when dentists must participate in the audit and dentists' right to appeal the findings.

By Cindy Hartwell, dental benefits analyst at CDA Practice Support.

When thinking about the seasons, we tend to associate them with certain activities. I love summer because it signifies the start of picnics and swimming. 
But also, every July, just like clockwork, CDA Practice Support starts hearing from members who have received notice from a dental benefit plan about a forthcoming audit.

Many dentists and their teams have not experienced a dental plan audit, and they have lots of questions concerning this practice. Many ask if it’s legal.

Post-pay audits: When dentists must participate

An often-overlooked portion of a dental benefit plan contract is the plan’s ability to conduct an in-office and/or chart record audit. These audits are post-pay audits, meaning the plan will review work and claims already completed, billed and paid by the plan. 

State regulators, such as the Department of Managed Health Care and Department of Insurance, require dental benefit plans to have quality management, utilization and antifraud policies and procedures in place to protect consumers. Performing these post-pay chart audits or reviews is one way dental plans comply with this requirement. 

However, dentists should be aware that if they are not contracted with the plan, they are not required to participate in a post-pay audit, as it is the participating provider agreement that gives the plan the authority to conduct this type of audit.

Prepayment review of claims may be required by a plan for both contracted and noncontracted providers. During a prepayment review, the plan may review a claim billed but not yet paid by the plan, and during the review the plan may request additional documentation from the dental office prior to processing the claim.

Overutilization of services billed can ‘trigger’ a chart review

During a post-pay audit, a plan may review the office’s chart to ensure that the dental procedures reported by a dental office were provided within the terms of the dental benefit policy and the participating provider agreement.

Often these types of reviews are triggered by a pattern of overutilization of services billed to the plan when compared to other dental offices. For example, if an office has billed the plan for scaling and root planing more often than other dental offices, the plan might suspect a pattern of overutilization. Once overutilization is identified, the plan may decide to review a sample of patient records to assess this irregular billing pattern compared to peer norm. 

The plan usually chooses a list of charts for review based upon the procedures it recognized as a concern. The plan may request the office’s records or conduct an on-site review in the dental office. In most cases, the dental office is notified by letter, which should include the course of action, a list of requested patient records or a date announcing the on-site review of records.

The dental office often must respond to the plan’s request within a specific time frame. The letter usually includes the contact information of the dental plan representative who can answer questions about the review process and sometimes grant an extension of time.

Dental offices should not be afraid to contact the plan representative to better understand the review process as this can help prepare them for what to expect. For example, the plan might request the patient’s entire record, including the patient ledger/financials. The plan will use that information to check that what was billed to the plan matches the patient record to ensure that the dentist is abiding by the contractual obligations laid out by the plan and agreed to during contracting by the dentist.

As I explained earlier, the plan will look for unusual billing patterns. Some patterns of interest include: 

  • Listing the incorrect treating dentist on a claim 
  • Billing for services not rendered 
  • Intentional misreporting the date the service was rendered 
  • Deliberate performance of unnecessary services
  • Reporting a more expensive procedure than was actually rendered (upcoding) 
  • A pattern of failure to collect a patient’s payment 

Dentists’ right to appeal the audit findings

Once the review is complete, the plan should provide its findings to the dental office. Sometimes the plan will put the dental office on a corrective action plan. Or, if the discrepancies found resulted in an overpayment by the plan, the plan may request a recoupment from the dental office.

A dental office has a right to appeal these findings. Although appealing the audit findings can be a time-consuming task, plans have adjusted the recoupment demand in some cases, while some dentists I’ve spoken with have seen the recoupment demand decrease. Dentists who wish to appeal a plan’s recoupment demand must send the appeal in writing to the plan within 30 days of the date of the notification per California law. 

To better prepare for (or even avoid) a dental plan audit, find the online course “Dental Benefits: Proper Charting and Coding” available through CDA 360°, CDA’s new destination for year-round learning. CDA members receive an exclusive 50% discount off the course.

For more resources on how to prepare for or avoid a dental plan audit, reference chapter 11 of CDA Practice Support’s Dental Benefit Plan Handbook and review our Clinical Chart Documentation Guidelines.