Audits by Insurance Companies
Many dental insurance companies do audits in dental practices in order to detect fraud (“Understanding dental plan audit authority” 2017). Dental practices under insurance companies must comply with their audits (“Understanding dental plan audit authority” 2017). Clinics should never engage in illegal activities, but organized records of their patients and bills shows insurance companies that they are billing patients and companies correctly.
Audits thoroughly check dental clinics’ billing practices and records. Insurance companies may do audits of the dental practices’ claims, checking their “business referrals, quality of care, documentation, coding, billing and licensure practices” for a variety of reasons (Liles 2017). For instance, they may hear of “a patient complaint regarding a specific service” (Liles 2017). Additionally, benefit plans may conduct a utilization review in order “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” (“Understanding utilization review and audits by benefit plans” 2016). If benefit plans suspect illegal activities, such as “Billing for services not rendered” and “upcoding,” during a utilization review, then they may perform an audit by “[reviewing] a sample of patient records to evaluate a dentist’s reporting pattern” (“Understanding utilization review and audits by benefit plans” 2016). Insurance companies want to check if the dental practices follow legal billing practices by checking, for instance, that the clinics consistently sent claims only for patients enrolled in their plan and claims for performed treatments (Oberman 2010). When an audit finds proof of abnormal billing patterns, such as overbilling, the dentist may have to refund the plan (“Understanding utilization review and audits by benefit plans” 2016). However, in another case, “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” (“Understanding utilization review and audits by benefit plans” 2016). Dentists could respond to the benefit plan’s request for a refund by “[negotiating] the recoupment amount” and “[utilizing their] appeal rights” (“Understanding utilization review and audits by benefit plans” 2016).
Based on these thorough audits, dentists should be prepared for them. The dentists and staff members must check that they are using the correct codes for dental claims and billing performed treatments (Liles 2017). Furthermore, dental practices should implement an “anonymous compliance reporting mechanism” and “[advise] and [train their] dental practice staff on their obligations to report improper billings or conduct to [their] practice’s Compliance Officer” (Liles 2017). For audits, they need to have proper records of their patients, treatments, services, billing, etc. because insurance companies “may analyze patient files,” ask for “documentation supporting submitted claims,” view records showing “an accurate reflection of services billed,” etc. (Oberman 2010; Understanding utilization review and audits by benefit plans” 2016).
Dentists may not be able to avoid audits forever. However, they can show insurance companies that they are not committing fraud in order to keep their practice open.