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Is Your Practice Prepared for a Dental Insurance Audit?


Does your practice have a compliance plan in place? Is there a designated compliance officer to make sure everyone is in compliance? What about documentation? Is it as complete and holistic as it needs to be? If you are unable to answer a resounding 'Yes' to any of these questions, your practice could be in jeopardy of a dental insurance claims audit.

"If for some reason you are billing differently than your peers, you’re going to pop up on the radar as an outlier" said attorney Ashley Morgan.

Dental insurance claims audits are on the rise, and one look at the landscape indicates the trend will continue.

Consider that, according to the Centers for Medicare and Medicaid Services, healthcare spending reached approximately $3.3 trillion in 2016. Roughly 4 percent, or $124.4 billion, of that $3.3 trillion was spent on dental services. Expenditures on dental services exceeded the amount spent on home health services, and was more than double the amount spent on durable medical equipment.

“If dental spending is matching the spending of other areas, it would make sense that dental is going to be highly targeted by Medicaid fraud control units,” said Ashley Morgan, a Senior Associate Attorney with the Washington, D.C.-based law firm of Liles Parker.

As such, understanding what a dental insurance claims audit is, what triggers an investigation, and how to prepare for it is critical for oral health practitioners.


There are essentially two different types of dental claims audits: a prepayment review, which is a review of claims prior to payment; and a post-payment review, where claims are reviewed after payment. According to Morgan, the post-payment review is the most common. In this case, an insurance company will identify specific patients and request copies of all those patient records between a designated time period, usually two years. To complicate matters, they will usually want to receive them within 30 days.

“They’re going to look at those records, and if they find issues with the documentation, such as some services don't qualify for coverage and payment under their rules, they will likely ask for those to be paid back,” Morgan explained.

Addressing a post-payment audit can consume large amounts of administrative time for a practice’s staff, as well as the providers, for pulling together all the requested records. Add in the possibility of needing to reimburse the insurer for non-qualified claims, and an audit can prove quite costly for a practice.

But it could get worse. If a dental practice does not have dental record documentation to support the services it claims were provided, the insurer might conduct a fraud investigation in the belief that the practice was billing for services that were not actually rendered. And that could lead to a criminal investigation.


Morgan said one of the biggest triggers of a dental claims audit is data mining, which is the practice of examining large databases in order to generate new information. And one thing the government and insurance companies are very good at is compiling a lot of information about their providers.

“They have all these different pieces of information,” Morgan explained. “And if for some reason you are billing differently than your peers, you’re going to pop up on the radar as an outlier. That would probably trigger them to have a closer look at your dental documentation, the type of services you’re providing, and the patients you’re seeing.”

An audit could also be triggered if a patient complaint is filed with either the state insurance board or the insurance company. For example, a patient might receive an Explanation of Benefits and report they did not receive the indicated services. Or, if you’re a Medicaid provider and are rendering a greater amount of services than have been identified as a risk to your geographic area, you could also trigger an audit.

Of course, there could be a very good reason why a dentist appears to be providing more services than his or her competitors. Often, it is due to improper billing.

“There may be more than one person in the practice providing these services, and [the office staff] is billing all of the services under one dentist’s number,” Morgan said. “You want to make sure you’re billing services provided by each dentist under their respective number.”


Perhaps the best approach to take where a dental claims audit is concerned is to assume that, inevitably, your practice will be audited at some point in time. Morgan said one of the best things dental providers can do is improve their documentation.

“If I take a look at one of your notes, it needs to tell a holistic story,” she emphasized. “You can’t just have an x-ray and indicate restoration in tooth number whatever. It needs to tell a complete story—how the decay was identified, and why the restoration needed to occur on this date of service—so that an independent third party can later read the note and understand what was happening.”

Morgan also strongly recommended conducting an internal audit of the practice’s documentation, and doing so by hiring an independent third party.

“They will provide better feedback than an internal review might do.”

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