Navigating quality assurance audits in the dental practice

By Ann Milar, CDA Dental Benefits Analyst

Quality assurance audits is not an earth-shattering topic overall, but it does affect most of the dentists in our state since a large percentage of dentists are contracted with more than a dental plan or two. Essentially, if you are a contracted participating provider with any dental plan, be it HMO or PPO, you are subject to quality assurance (QA) audits by virtue of your signed participating provider agreement.

At the beginning of the year, a few hundred dentists received a letter or telephone call from a dental plan indicating that they had been selected for a quality assurance audit. Below I address common dentist questions and offer a few suggestions for navigating the audit process.

Yes, they can do this

First, take a deep breath and do not panic! All Knox-Keene licensed dental plans in California are required to audit their provider networks as part of the plans’ licensure requirement with the Department of Managed Health Care. As a contracted provider with one of these plans, you have agreed to this process via your provider agreement. Failure to comply with this process could result in termination of your provider agreement with the plan.

It is a numbers game

Generally speaking, dental offices are randomly selected for quality assurance audits. Let me restate this in another way … filing a claim appeal did not result in your audit, neither did filing a provider grievance. Plans randomly select dental practices for quality assurance audits. I suggest envisioning the process as similar to the method used for pulling lotto numbers each week (it may make you feel a little better). In those instances when the audit is incident-driven, the plans will request patient records and notify you that they are auditing the practice as the result of a specific (or multiple) patient complaint(s).

Be prepared

In preparation for the audit, I recommend dentists review their provider agreement and provider manual and/or handbook to re-familiarize themselves with the criteria for which the plans hold them accountable. Plans are required to outline the audit criteria for their network in their plan documents. For dentists who went through a QA audit several years ago, the criteria may be more stringent than they remember. Plans are being held to increasingly higher standards and, in turn, must hold their providers to these standards as well.

The envelope, please

It is important to note that the plans do not want providers to fail their audits; they want to demonstrate to the department that they have a quality network that provides excellent treatment for their plan enrollees. Dentists can expect a letter after their plan audit, which includes a summary of findings. The findings may note deficiencies or offer recommendations for improving plan compliance and may request a dentist response. Depending on the severity of the findings, the plan may re-audit the dentist in a few months, in a year, or, in those rare instances when the findings are egregious, terminate the relationship with the dentist altogether.

Just as you have required processes and procedures in your dental practice to ensure patient safety and appropriate treatment, the quality assurance audits are a tool utilized by the dental plans to ensure that their enrollees are receiving a true dental benefit with quality care and appropriate access.

For more resources regarding quality assurance audits, visit our Practice Support area.