There are two types of audit that rely heavily on patient records: an insurance company audit and a state dental board audit. I’ve been lucky enough to survive both.
It seems that some dental personnel don’t understand the impact their notes have on any type of audit or patient care. How can anyone fail to grasp the importance of each note and/or documentation recorded, and what legalities could be involved? It seems to be the hardest system to get in place, regardless of how many auto-notes or shortcuts are provided to assist in properly completing records.
Today, standing in a team huddle, I was stunned when a dental assistant actually said, “I think we should get a pass for any notes we didn’t write yesterday, since we were so busy.” It didn’t take long for my response: “If the state dental board came in today to perform an audit on yesterday's charts, would the doctor get a pass because he was so busy, or would he be fined or his license suspended, depending on the reason for the audit?”
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When conversing with our state dental board investigator, she told me to always remember and emphasize the following: If it isn’t documented in the patient's record, then you didn’t see it, didn’t say it, didn’t do it, and it didn’t need to be done, therefore, it didn’t exist.
Always make a chart note, even if it was a no-charge procedure. The examiner stated to keep in mind that it doesn’t matter who did not do proper documentation or proper billing, the bottom line is, the doctor will be the one affected by audit consequences.
Dentists selected for an audit have only their records to protect them. Effective chart notes and radiographic images are essential.
In an audit, an insurance company will request up to 50 records by letter, email, or phone call. Never give more and never less than the insurance company requested. Give them exactly what they’ve asked for. The items requested are to compare documentation against the charges billed out.
The request usually consists of the following information:
- Notification of date and time
- Patient medical history
- Progress notes
- Perio charting
- Signed treatment plans
- Patient evaluation data
- Lab case prescriptions
- Lab case invoice
- Specialist communications
- Patient ledger
The insurance audit representatives will be checking for things like:
- Charges match chart notes
- Charges billed were completed
- Materials billed were those used (e.g., PFM, zirconia, composite)
- Quality of the office
- Adherence to contractual obligations and the regulations set by the state and/or federal government
- If the office procedures are “outside the norm,” the audit representative assures and/or determines why the charges or treatment mix is different from other providers
- X-rays charged were of diagnosable quality, showing the correct part of the tooth, jaw, and/or face that is being addressed
If a patient complains to an insurance company, the insurance company and the dental board can request before and after x-rays, photos, and chart notes for review. If treatment is deemed substandard, you will be requested to refund the insurance company and the patient for the total amount paid to you for the procedure under review. These complaints can also throw a red flag for a complete open review. During a full audit, anything found unacceptable is charged/fined to the provider, not for just that procedure, but for all procedures ever paid to you with that code and a percentage calculated, times three.
State dental board audits
The state dental board will follow most of what the insurance company audit is requesting, but are more case-specific. Usually, these audits are due to a complaint by a patient. Remember, if it isn’t charted, then it didn’t happen. Chart and scan everything thoroughly.
Yes, I sadly survived this one too. A coroner’s audit will start with a request for the patient's chart and notes to review the steps taken during the patient’s appointment. They will want to check to see if there was a review of the patient’s medical history. If there was documentation of any known heart ailments from the patient’s physician (including the need for premed, etc.), as well as things such as what type, what time, and how many carpules of anesthetic were administered.
What we did find absolutely necessary was an emergency contact number for family members. Our patient did not include one on their registration form, but we fortunately knew what school her children attended, so we called the school and they contacted the patient's parents for us. (This should have never happened this way. It’s important that the person entering the data realizes that this information is imperative.) Also, we had to show that we maintained appropriate CPR certifications, an emergency office protocol, our doctor’s license, the doctor’s immunization record, and the assistants’ radiology licenses and immunization records.
Always be prepared for an audit by making sure your staff records comprehensive, up-to-date records. Be familiar with the CDT code being billed and check that it’s the appropriate one to match the notes. Also, keep written office systems and protocols in place and adhere to them. Last but not least, you’ll be fine if you and your team are always prepared for the unexpected.
Editor's note: Originally posted in 2021 and updated regularly