What you need to know to pass a dental insurance claims audit

Nov 4, 2019

The number of dental insurance claims audits is rising -- and a quick look at the figures indicates the trend is very likely to continue. Healthcare spending in 2018 was at $3.647 trillion, according to the U.S. Centers for Medicare and Medicaid Services. Of this total amount, $134.0 billion (approximately 4%) was spent on dental services. This sum exceeded the home health services expenditures and equates to more than double the amount spent on durable medical equipment.

When the amount of money spent in the dental sector matches or surpasses the spending in other medical areas, it's not surprising that the industry is becoming the target of Medicaid fraud control units. Therefore, understanding exactly what a dental insurance claims audit involves, what the most common triggers are, and how you can thoroughly prepare your practice for one is vital to keeping your dental practice's doors open.

What is a dental insurance claims audit?

Two types of dental insurance claims audits can occur. The prepayment review analyzes the claims made before payment was received, and a postpayment review inspects the claims made after payment was received.

The postpayment review is the most common of the two and usually involves the insurance company requesting copies of selected patient records between a designated time period (often 24 months). As if it weren't challenging enough to provide this documentation, insurance companies often demand the paperwork is delivered within 30 days of the request.

The insurance company will review the paperwork in search of discrepancies, such as services that don't qualify for coverage and payment according to its policies. If it discovers anything like this, it's common for the insurer to ask for the amount to be paid back.

In the unlikely scenario that an insurance company asks for patient documentation a dental practice is unable to produce, the insurer will consider conducting a fraud investigation to find out if the practice was charging for services that were never carried out. This could quickly escalate into a full-blown criminal investigation.

Going through a postpayment audit can be incredibly time consuming for the team members who have to prepare the paperwork. Whoever ends up taking on the task, it's likely that their time would be much better spent helping to treat patients than it would doing this.

If you're subject to a dental insurance claims audit and you don't want to take your best team members away from their patients, consider hiring temp staff through a cloud-based dental professional matching platform. With Cloud Dentistry, you can browse the profiles of hundreds of dental professionals, including front office staff who are well prepared to handle audits. They can take care of all the paperwork and ensure the insurance company is satisfied, while your dentists and team members focus on their patients, their well-being, and their happiness.

What triggers a dental insurance claims audit?

Data mining is the main trigger of dental insurance claims audits. This involves insurance companies reviewing huge databases in search of new information. They compare data across a large number of different dental practices, and, if for any reason yours stands out from the rest, you're going to appear on their radar as a practice of interest.

For example, if the database reveals that you bill slightly differently than your peer practices, it's in the insurance company's best interest to have a closer look at your dental documentation, the services you provide, and the patients you treat.

Appearing to be treating significantly more patients than peer practices is another common trigger. This is something that is often seen due to improper billing.

For example, your practice might have more than one dentist performing the same services. But instead of billing each treatment under the individual dentist's number, the front office team bills all the services under just one dentist's number, which naturally confuses the numbers.

To avoid this, it's important you employ competent, qualified admininstration staff who understand how important it is to bill the services each dentist provides under his or her respective number.

How can you prepare for a dental insurance claims audit?

Although some practices can go the stretch without ever being audited, it's wise to assume your practice is going to undergo a dental insurance claims audit and be prepared for it.

Start by improving your documentation, making it as clear and detailed as possible. You need to think about it from an auditor's perspective. If the auditor were to pick up a file and look at the notes regarding the patient's last treatment, it's important the persion fully understands how the necessity of the treatment was identified, what caused the treatment to be needed, how the treatment was carried out, etc. Provide as much information as possible, so if questions are asked years later, everything is clear in front of you.

After your documentation is up to scratch, you need to work on your filing system. Whether you work with modern digital files stored in the cloud or a traditional paper system in a filing cabinet, ensure all patient paperwork is properly filed and you can find the exact file you need with minimal fuss when required.

Trey Tepichin is the co-founder and chief executive officer of Cloud Dentistry, an online company that matches dental offices with specialists, dentists hygienists, and dental assistants, all with just a few clicks.

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