Is your practice prepared for a dental plan audit?
The word “audit” can create anxiety for most dentists, but taking preemptive measures before an audit happens can reduce your stress and liability should you ever have to comply with a dental plan’s request to audit your practice.
Why dental plans conduct audits
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 the enrollee (patient). These regulations require a contracted provider to allow the plan access to the books, records and papers of the contracted provider who provides services to their enrollee. For additional information on dental plan audits refer to Chapter 11 of the Dental Benefit Plan Handbook: Understanding Dental Benefit Plan Audits.
Thorough documentation is key
Dental plan audits do not require the patient to be physically present. The auditor will rely on the information that is documented in the patient’s chart. Chart notes and treatment notes should be detailed enough to support the necessity for the treatment or the condition of the patient’s oral health. Keep in mind that documentation is not limited to chart and treatment notes; radiographs and other imaging are considered documentation and should be of diagnostic-quality as well. For more information, see Patient Records – Requirements and Best Practices.
Audits extend beyond patient charts
The patient ledger and billing record are also considered part of the patient’s chart. Depending on the type of audit, the dental plan can request to review the patient ledgers and billing history. A dental plan reviews patient ledgers to ensure that the patient and the dental plan are being billed according to contractual requirements, which include collection of patients co-payments, discounts given and, if applicable, ensuring that upgraded treatment has been properly billed.
Auditors may also request to view a copy of your schedule for the dates that the patients were seen in the office to ensure enough time was permitted to treat the patient. If the auditor requests to view the schedule, be sure to redact any patient information that is not specific to the current audit. Additional information can be found in Chapter 5 of the Dental Benefit Plan Handbook: Working with Patients and Their Plans.
One final note: If you are not contracted with a plan, that plan cannot require participation in an office/chart audit, but if you voluntarily agree to the audit, you will likely become obligated to open the patients’ records for review by the plan.
For additional information or assistance with a dental plan audit, please contact Practice Support.