Insurance plans have audit authority to conduct postpayment chart reviews through participating plan provider contracts. These chart reviews are required by state regulators, such as the Department of Managed Health Care and the Department of Insurance, to ensure that dental procedures reported on claims submitted by a dental office on behalf of an enrollee are consistent with the treatment documented in the patient's chart.
Sometimes these chart reviews are triggered when potential patterns of overutilization of services rendered are identified through a plan's system analysis via peer comparison. For example, a dental office that performs scaling and root planing more frequently than other offices could raise a red flag with the plan. Of course, the plan may find during these types of reviews that the dental practice is just very busy in comparison to other offices and the treatment was warranted.
Again, it is important to understand that the dentist has agreed to these types of reviews by signing the participating provider agreement with the dental plan. But what happens when a dental plan requests a chart review or audit and the dentist is not a contracted participating provider?
When not to comply
Dentists should understand that they are not obligated to comply with a request for a postpayment chart review by a plan in which they have no contract.
“Dentists need to be informed of their responsibilities or lack thereof.”
The CDA has received an uptick in calls recently from dentists who received a request for chart review from dental plans but were unaware of their rights as a noncontracted dentist. By voluntarily complying with the plans' requests to review their charts, some dentists are now facing significant recoupment demands from the dental plans.
The association has communicated with the dental plans about the questionable practice of soliciting chart information from noncontracted dentists to conduct these audits. These insurers maintain that they have a responsibility to their subscribing groups to guarantee that claims were paid correctly and that these types of audits help them to determine the accuracy of claims processing.
The CDA maintains that authority to conduct such chart reviews only exists within a plan's participating provider agreement with the dentist. If there is no agreement, there is no authority to conduct these types of reviews.
However, plans conducting this type of outreach hold to the opinion that if they request a postpayment chart review from a noncontracted dentist and the dentist agrees to the review, the review will move forward.
For this reason, dentists need to be informed of their responsibilities or lack thereof. It is often a good idea to reach out to your local or state dental association before complying with a plan's request for this type of review.
DrBicuspid.com wishes to thank the California Dental Association (CDA) for allowing us to reprint this article, which originally appeared on the CDA website.
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