What to expect during a dental plan utilization review

By Denise Martinez, CDA Sr. Dental Benefit Analyst

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

Recently, CDA has received an increase in calls about these types of reviews by the dental plans. Utilization review is a post-claims review process that can affect dentists who treat patients covered by a dental benefit company. Therefore, it is important that dentists understand the complete utilization review process. 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 review process:

Data collection and statistical analysis

The utilization review process begins with a post-payment review that may result in identification of 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 as a result of an inquiry or complaint 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

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 they have 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 amount of patient records requested for review can vary from five to 25 records, possibly more. Many dentists find the process of copying records to be cumbersome and time-consuming. If you are a contracted provider, it is likely your provider agreement with the plan requires you to comply with these types of requests. 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. Be aware that there is typically a specific timeframe to respond to the request and you should respond within that period. Normally, the letter will have contact information for a person at the dental plan to discuss and answer questions about the utilization review and even ask for an extension of time. Don't be afraid to contact them to discuss clinical or policy related questions, as well as to better understand the utilization review process and what to expect.

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.

Review results

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

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 and/or requests for predetermination. The monitoring can last for several months and if improvement is not seen, a dentist may be terminated from the plan.

Increasingly, CDA Practice Support has heard from members who have gone through the utilization review process, and that there have been findings of improper documentation in their patient records. This may result 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, make sure records can always support the treatment rendered. CDA Practice Support is available should dentists need assistance with a utilization review.

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Navigating the dynamic world of dental benefits is key to managing a smart practice. The Dental Benefits Workshop provides participants the opportunity to earn 12 C.E. credits during a two-day, in-person seminar. They will learn how to analyze and evaluate existing dental plan performance in their offices while getting hands-on experience from industry experts on how to navigate the world of dental benefits.