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​Dental News and Notes

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September 2, 2019

Don't be caught unprepared - Here's why you should self audit.

Computer technology has come a long way; reviewing and comparing claim data for each individual provider is quite easy.  Dental benefit companies and third -party administrators have the ability to monitor, mine and store data submitted by your office.  With a simple click of the mouse, payors can compile and compare treatment patterns and billing frequencies.  Many payors share provider and network data with other third-party payors.

No matter what, a pending insurance audit can create many sleepless nights or be nerve-racking to say the least.  Insurance audits are performed regularly by payors.  Insurance carriers have a fiduciary responsibility to their plan holders and are looking to keep premiums down in cost to attract potential clients.  Insurance payors and third-party administrators are very attentive to “their bottom line” and to that of their clients (plan holders).  In order to identify that contractual obligations are being adhered to between insurance carriers and plan holders and that state and/or federal government mandates are being upheld by the providers, many providers are randomly chosen for audits, while others are purposely selected as a result of patterns in their claim submission history.  Either way, the focus of an audit is to verify that the treatment billed was medically necessary, properly performed and accurately billed.

If your office gets “flagged” by a payor as having a claim submission pattern that is outside the statistical norm, your office may experience some additional challenges in getting claims paid. Typically, you will be asked to provide more documentation than was previously required.  This is to justify and support the need for the services you are providing.  Back in the day, this was referred to as “focused review”.  If sufficient information is not provided, the claims will not be reviewed.  If you are a contracted provider, it’s more likely you could become the lucky recipient of an office audit.

The purpose of an audit is multifold.  One goal is to ascertain why a doctor’s treatment and/or billing patterns are substantially different from other providers in their network (in a given geographic area).  While there may be a completely legitimate and reasonable explanation for the deviation, the red flag goes up nonetheless.

Knowing this type of scrutiny in inevitable, you can take this opportunity to self-audit your office and clinical documentation; you may be surprised.  Review your findings and inconsistencies and implement policies and processes to be more consistent, more efficient and more accurate.  The bottom line is you can be pro-active and implement change if necessary.

Here are some basics to get you started.

Was the procedure submitted actually performed?

Does the documentation support the treatment?

Was the claim accurately submitted?

Were the fees reported consistent with what was submitted and intended to be collected?

Let’s talk about something simple like bitewings:

We all know a dental office can be a busy place.  Sometimes staff routinely submit for procedures without double checking there was no variation in the normal routine.  For example, bitewing films.  If you submit a claim for 4 bitewings, then the auditor will likely look at the chart and the films to make sure you indeed did take 4 bitewing films, that they are all of diagnostic quality and that the bitewing radiograph provides a clear view of the interproximal of the distal of the canine to the mesial of the third molars.  Why?  Because that is the geographic area a bitewing radiograph should capture.

Something to note!  Non-diagnostic images may not be eligible for reimbursement as they are considered, well quite frankly, “useless”.  If the carrier issued a benefit for these films previously and finds they are not of diagnostic quality upon inspection, you may be asked to return the benefit.

So we established that the procedure was “actually performed”, and that you did indeed take the number of films you reported – BUT does the documentation support the treatment?  We should all be aware that the FDA and ADA revised their criteria for taking films in 2012.  Dental professionals should recommend radiographs based on patient history, chief complaints, medical necessity and professional judgement.

Do your chart notes indicate WHY you are taking the films?  Did you include an updated history?  Did the patient fall, are they having sensitivity?  Are they a high caries risk?  Are they on meds?  Those types of informational tidbits should be in your supporting documentation.  Taking films every 6 months because it’s a recall appointment isn’t going to cut it anymore. WHY do you need films?  Does the documentation support the treatment?  Well, having no documentation means there is no reason why…..  no reason why equals grounds for benefit recovery. ( at least in the world according to Joan)

Lastly, the fees on the claim form should be consistent with the fees in the patient’s ledger.  If you don’t charge for films – then it needs to be documented in the chart, the ledger and on the claim form.  If your ledger fees are aligned with the claim fees, then you should be ok.

So, who would think something as simple as 4 bitewing films on a recall requires so much attention.  Easy peasy, right?

You got this.  You can drill on a moving target, handle unrealistic patient expectations and jump through hoops to get your reimbursement.  Once you get the reimbursement, let’s try not to provide any reason why you should have to refund it back.

We are operating in an environment where it is assumed most of us wealthy dentists  are dishonest or working the system.  Let’s not give them any ammunition. Do the self audit, you may be surprised and better prepared.