Understanding utilization review and audits by benefit plans

As part of a contractual commitment the dental benefit plans have with their consumers (employer groups and their employees), the plans are required to have a claims utilization review and audit process. State regulators, such as the Department of Managed Health Care and Department of Insurance, also have requirements for the dental benefit plans to have antifraud policies and procedures in place for all insurers.

CDA is receiving an increasing number of calls about these types of reviews and audits as dental benefit plans continue to perform more of them. Utilization review can affect dentists who treat patients covered by a dental benefit plan; therefore, it is important that dentists understand the complete utilization review process since it can result in an audit of a dentist's patient records. The utilization review process is designed to ensure that dental procedures reported on behalf of plan enrollees, by their dental office, are rendered consistent within the provisions of the benefit plan and the participating provider agreement.

What to expect during the utilization review process

The utilization review process begins with a post-payment review that may result in identification of a potential concern. According to the benefit plans, the concern is generally identified when there is a pattern of over- or under-utilization of services identified through statistical analysis of peer comparison, utilization data and/or dentist practice patterns. It can also occur because an inquiry or complaint was received from a patient or another dentist, and even from discrepancies noted during claims processing.

Ultimately, the benefit plan is looking to identify those dentists who could potentially be providing services outside the community standard or the benefit plan's guidelines. The utilization review is also designed to identify fraudulent billing patterns.

Types of issues the plans are looking for:

  • Billing for services not rendered.
  • Intentional misreporting of procedure, date of services, identity of the dentist or identity of the patient.
  • Deliberate performance of unnecessary services.
  • Alteration of patient record.
  • Reporting a more expensive procedure than was actually rendered (upcoding).

Professional review/audit of patient records

Based upon the results of the analysis, the dental plan may decide it is necessary to review a sample of patient records to evaluate a dentist's reporting pattern. The plan usually selects the patient record list for review based upon the procedures it has identified as a concern. The records may be requested from the dentist or an on-site review may be conducted in the dentist's office. The number of patient records requested for review can vary from five to 25, possibly more. Many dentists find the process of copying records to be cumbersome and time-consuming.

Contracted providers are likely required to comply with these types of requests, according to their provider agreement with the plan. However, if a dentist is not contracted with the plan, the dentist is not contractually obligated to comply with the plan's policies and procedures.

Generally, the dentist is notified by letter, which will include relevant guidelines, a list of requested patient records or information announcing the on-site review of records. Providers should be aware that there is typically a specific timeframe to respond to the request. Normally, the letter will include contact information for a dental plan representative who can discuss and answer questions about the patient record review and even grant an extension of time. Dentists should not be afraid to contact the plan representative to discuss clinical or policy-related questions, as well as to better understand what to expect during the utilization review process.

The dental plan will review the records, which usually involves an administrative person and a licensed dentist for clinical perspective. The entire record, including treatment notes, X-rays and all diagnostic materials, will be reviewed and compared to claims submitted for payment to the dental plan for services rendered by the dentist. This review will determine whether the records adequately document the services reported on the submitted claims to the dental plan.

Reviewing results

Upon completion of the record review, the findings should be provided to the dentist. If any discrepancies are identified, a detailed report is provided. Corrective actions may be required; if the discrepancies found resulted in an overpayment, the plan may calculate and request recoupment from the dentist.

CDA members who have experienced recoupments reported that it has been beneficial to appeal the findings that resulted in recoupment. While this may be time-consuming, the benefit plans have made considerations and some members have seen their recoupments significantly reduced. In addition, we have learned that benefit plans will often negotiate the recoupment amount, making it beneficial to have a conversation with the reviewing dentist or administrative contact person and request a lower recoupment amount.

Prepayment and special claims review

If the dental plan identifies problems of a repetitive nature during record review, a dentist may be placed on a special claims and/or prepayment monitoring. This type of monitoring may require the dentist to submit additional supporting documentation beyond the standard plan policy when submitting claims or requests for predetermination. The monitoring can last for several months, and a dentist may be terminated from the plan if improvement is not seen.

Increasingly, CDA Practice Support has heard from members who have gone through the utilization review process and have reported findings of improper or inadequate documentation in their patient records, ultimately resulting in negative actions toward the dentist.

Tips for accurate dental record

  • Note the site of service.
  • Documentation for each service performed should include the reason, any relevant history, physical examination findings, assessment, clinical impressions, diagnosis, treatment plan, date and treating dentist.
  • Documentation should support appropriateness of billing.
  • Dental record should be complete and legible.

Record-keeping is an essential part of a dental practice, and while a practice may never have a review like this, providers should make sure records always support the treatment rendered. It is always recommended to bill for what is done, not what the benefit plan will pay for, and to ensure treatment records are an accurate reflection of sevices billed.

Dentists who need assistance with a utilization review or chart audit can contact CDA Practice Support at 800.232.7645.

Patient Record-Audit Checklist

  • Comply only if you are contracted with the benefit plan
  • Provide completed quality copies of the chart
  • Provide good-quality diagnostic radiographs
  • Be sure to keep a diagnostic copy of radiographs for your records
    • Benefit plans do not return radiographs
  • If audit results in recoupment, utilize your appeal rights
  • Request peer-to-peer conversation with the reviewing dental consultant
  • Negotiate the recoupment amount

Related Items

SB 137 requires dental plans to comply with uniform standards and provide timely updates for their provider directories and there are two numbers you need to know to ensure compliance with the new law that goes into effect July 1 — 30 and five. The goal of this legislation and resulting regulations is to provide patients with more accurate information to identify which dentists are participating with their dental plan.

There is an ongoing trend within health care toward integration and consolidation of health care delivery systems. This trend is reflected in provisions of the federal Affordable Care Act, such as the envisioned coordination of care provided under a single entity, the “Accountable Care Organization.”

Dental practices should not ignore any email from the HHS Office for Civil Rights (OCR) as the agency announced that it has started the next phase of audits of HIPAA covered entities and business associates. The emails have been sent to verify contact information.