How to prevent an insurance audit

2019 09 24 21 39 2685 Anderson James 400

Do you ever think that your treatment decisions regarding patients will ever be considered questionable? If you bill insurance companies through a private payer preferred provider organization (PPO) or dental health maintenance organization (DHMO) network, they are governed by contractual rules and some state regulatory agencies. If you bill through a federal government entity such as Medicaid or Medicare, you are under the scrutiny of the government to abide by their rules and regulations.

Dr. James V. Anderson.Dr. James V. Anderson.

If you sign a contract, you must read it first. Providers of the plans must adhere to the contractual requirements. There is a processing policy manual with each plan that specifies the provider's obligations and legal responsibilities.

An audit is a review of records by a dental payer to ensure that providers uphold responsibilities regarding plan specifications, along with applicable state and federal laws. Any violation found during an audit could result in the payers' request for repayment of funds paid to the doctor, sanctions, being dropped by the PPO, or being referred to the State Dental Board for further review.

There is more than one type of audit depending upon the collected information that leads to the audit. More commonly, there are two types of audits, a utilization review and a focused review. The two are similar, but a focused review requires a higher level of scrutiny and takes more time to complete.

What to know about modern audits

Advancements in audit technology have created a better way to measure accountability and spot potential fraud. For insurance payers, it is easy to acquire, store, and analyze large amounts of data demonstrating billing trends by state and zip code.

Insurance payers can collect and compare doctors' treatment patterns and billing frequencies submitted by individual providers. For instance, if 90% of new patients in one dentist's practice received scaling and root planing, but at the neighboring dentist's practice, only 40-50% of the patients were diagnosed with scaling and root planing, this practice could be flagged for overutilization of a service.

Before embarking on any contractual relation with any entity that is expected to pay on a patient claim, you must be able to verify that the treatment was necessary, was standard of care, and was accurately reported. Coding and supporting documentation of radiographs, periodontal charting, intraoral photos, scans, and detailed clinical notes will be analyzed in an audit.

Some dental services are more often flagged than others. These include high crown-to-filling ratio, scaling and root planing, core buildups, resin-based anterior restorations that include the incisal edge, periodontal maintenance versus prophy, and extractions versus surgical extractions.

Another reason you may feel the pain of an audit is patient complaints.

Depending on which entity receives the complaint, the audit may vary. Was the complaint by the patient to the insurance plan to the state board or both? Most often, they will request all ledgers, all treatment plans and clinical notes, and all supporting documentation.

Tips for preventing an audit: Document, document, document

What to document

  • Document medical history and update it when the patient is in for an appointment.
  • Document assessment of findings and clinical impressions.
  • Describe all services performed. Ensure diagnosis and treatment plan all treatments in the chart.
  • Provide quality radiographic images, photos, diagnostic study models, and periodontal 6-point charting.
  • Note the findings of radiographs in the chart.
  • Provide informed consent signed by the patient for all procedures.

Tips for submitting claims

  • Properly code the services using the most current year Current Dental Terminology (CDT) manual.
  • Provide narrative and documentation for the claim form supported by clinical facts.
  • Post the document immediately to the clinical record/date/treatment.

Other tips

  • Keep clinical records separate from financial records.
  • Follow HIPAA laws and regulations and the Americans with Disabilities Act (ADA) and U.S. Food and Drug Administration recommendations for prescribing dental radiographs.
  • Take photographs before and after treatment.
  • If you use paper records, do not use markers or erase them to remove an entry. Follow your state laws for changing or amending a clinical history.
  • Do not document disparaging remarks or personal opinions about the patient on the record.


Be meticulously diligent in how you document patients' charts. Listen to your patients and give the best customer service to prevent complaints against your practice.

Understand and follow the PPO agreements and the Provider Manuals of all plans that you are under contract.

Don't leave anything to the imagination with clinical charting and treatment planning. Auditors cannot read between the lines.

The goal is to operate your practice with established written standards. Demonstrate compliance with insurance regulations and backed by excellent recordkeeping.

Dr. James V. Anderson is a practicing dentist in Syracuse, UT, and is the CEO and founder of eAssist Dental Solutions. He can be reached via email.

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.

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