Pause before you comply with a plan's request for post-payment chart review

Dentists can avoid unnecessary stress by seeking guidance from CDA Practice Support before complying with a dental benefit plan’s request to conduct a post-payment chart review of patient records. 

In a previous Update column, I shared information about plans’ audit authority to conduct post-payment chart reviews and how the plans have this authority through participating plan provider contracts. Post-payment chart reviews are required by state regulators, such as the department of managed health care and the department of insurance. Performing these post-pay chart audits or reviews is one way plans ensure that dental procedures reported on claims submitted by a dental office on behalf of an enrollee are consistent with the treatment documented in the patient’s chart.

Sometimes these chart reviews are triggered when potential patterns of overutilization of services rendered are identified through a plan’s system analysis via peer comparison. For example, a dental office that performs scaling and root planing more frequently than other offices could raise a red flag with the plan. Of course, the plan may find during these types of reviews that the dental practice is just very busy in comparison to other offices and the treatment was warranted.

Again, it is important to understand that the dentist has agreed to these types of reviews by signing their participating provider agreement with the dental plan. But, what happens when a dental plan requests a chart review or audit, but you are not a contracted, participating provider?

When not to comply

Dentists should understand that they are not obligated to comply with a request for a post-pay chart review by a plan where they have no contract.

CDA Practice Support has received an uptick in calls from dentists who received a request for chart review from a plan but were unaware of their rights as a noncontracted dentist and, unfortunately, did not call Practice Support for guidance. By voluntarily complying with the plans’ requests to review their charts, some dentists are now facing significant recoupment demands from the dental plans.  

CDA has communicated with the dental plans about the questionable practice of soliciting chart information from noncontracted dentists to conduct post-pay audits. The dental plans maintain that they have a responsibility to their subscribing groups to guarantee that claims were paid correctly and that these types of audits help them to determine the accuracy of claims processing.

CDA maintains that authority to conduct such chart reviews only exists within a plan’s participating provider agreement with the dentist. If there is no agreement, there is no authority to conduct these types of reviews.

However, plans conducting this type of outreach hold to the opinion that if they request a post-pay chart review from a noncontracted dentist and the dentist agrees to the review, the review will move forward.  

For this reason, dentists need to be informed of their responsibilities or lack thereof. To help ensure a good outcome for you and your practice, reach out to CDA Practice Support prior to complying with a plan’s request for this type of review. CDA is here to help our members protect their rights and those of their patients when dealing with dental benefit plans.

To learn more or to submit a dental benefit issue, visit the Dental Benefits Plans page at CDA Practice Support.

This column was authored by Cindy Hartwell, dental benefits analyst at CDA Practice Support.

Related Items

If you haven’t heard, CDA recently launched a new process for members to report issues and questions related to dental benefits. Although CDA members have had access to a dedicated dental benefits analyst and Practice Support resources since 2009, the online submission form makes it easier for dentists to quickly reach out for assistance and submit their issues 24/7.

Delta Dental of California notified California dentists in its FYI newsletter that dentists should be prepared for a quality assessment review. CDA members are encouraged to review the on-site QA review checklist provided in the April 9 newsletter to ensure compliance. On-site reviews are part of Delta Dental’s quality assessment program for contracted dentists in California, mandated by the California Department of Managed Health Care.

An often overlooked but very important component of contracting with a dental benefit plan is the plan’s authority to audit charts or records. State regulators require dental benefit plans to have quality management, utilization and antifraud policies and procedures in place to protect the insured. Performing these post-pay chart audits or reviews is one way plans comply with this requirement. They conduct these reviews to ensure that dental procedures reported by a dental office on behalf of an enrollee are consistent within the provisions of the dental benefits.