Preventing an Audit means being Proactive

I know, I sound like a broken record when I say, “If it isn’t written it didn’t happen.” This is in the context of creating narratives for claims when there are NO CLINICAL CHART NOTES.  Leaving your staff to read x-rays for which they aren’t licensed and create, or make-up plausible evidence of the services rendered so that the claim will get paid is common procedure for some busy dental practices.   

Recently, I experienced poor record keeping at my physician’s office.  I had a vaccine for the prevention of pneumonia a year ago and I thought I was covered.  When I was in the office for a routine appointment I was told I had never received the pneumonia vaccine. I didn’t receive a walk out statement and it wasn’t recorded in the chart, so it didn’t happen.  I started to question my own memory even though I knew I had received the vaccine.

In an audit, without good records, your memory doesn’t amount to a “hill of beans.”   Let’s face it if you didn’t record the treatment with supporting documentation the insurance company can say, “It wasn’t necessary treatment, or it didn’t happen, so you must return $___________.”    Oh, now you are listening!

Insurance audits are routine by payers who are doing some quality control to verify whether the providers of service are abiding by their contractual obligations and that they are also following state and federal regulations.

The advancement of technology allows the insurance industry to compile fact-based numbers to study for various reasons and trends.   With technology as a tool, the insurance company audit is often driven by numbers and not patient or other whistleblower complaints as in the past.

What is an auditor looking for when they look at your records?

It is important to remember that just because there is a benefit for a service a couple of times a year doesn’t mean that it is charged on everyone just because it is a covered benefit.  For instance, my husbands Delta policy pays for a dental evaluation every 6 months. His dentist does one a year but on the second yearly visit, his dentist sticks his head in the door and asks the hygienist how things look.  She says, “He looks good.”  That was the extent of the evaluation.   It was billed to Delta and they paid for it.

In the event of an audit, if patients without dental insurance were not charged every 6 months for an evaluation it would raise a red flag that treatment protocols were different for patients with insurance versus patients without.  In order to bill for the evaluation, the criteria for the evaluation must be provided to the patient and clinical notes must reflect what and why the evaluation was performed.

According to Coding expert, Dr. Charles Blair, http://drcharlesblair.com/,   “It is considered illegal by some state and /or federal regulations as well as unethical by the ADA to charge different fees based on insurance coverage.   Treatment protocols should be identical for patients with or without insurance coverage.”

In an audit of records, the auditor is looking to see if insured patients are being charged more or for services that are discounted or not charged to cash patients.

The auditor is also looking for evidence that the procedures were actually performed. If the practice is billing for 4 bitewings, were the bitewings actually taken and are they of good diagnostic quality and were they reviewed, and the results documented?  The auditor may be looking for the clinical reason that the x-rays were taken on this particular patient and subsequently reviewed. Statements such as “no caries visible” or “bone level normal” that would prove the radiographs were necessary and reviewed by the dentist.

The dental record must mirror the information on the clinical chart and patients must be treated equally whether insured or not.

There is much more to an audit and it is important to have good records to prevent you from facing possible fines or other punitive actions.

Be proactive and write good clinical notes to backup your rationale for services offered to all patients.

Dental Billing Tips and News for Pros; Edition #133