Content Dam Diq Online Articles 2018 03 Audit 1

Have you been the target of a dental insurance audit?

March 16, 2018
There are steps dental front office staff members can take to to either prevent or address a dental insurance audit. Here is what has worked for the practice where the DOMD editor works.
Kyle L. Summerford, Editorial Director

This article originally appeared in Dental Office Manager Digest e-newsletter. Subscribe to this informative monthly ENL designed specifically for the dental office manager here.

Dental insurance companies typically pay for the usual preventive services and even some basic services without hesitating. But when it comes to major services and large payout amounts, some insurance companies ask for treatment notes and other supporting documentation. This triggers what most people describe as an insurance audit.

Most of the time offices can submit a patient’s dental claim and expect prompt payment, as long as the usual supporting information is provided, such as dental x-rays and periodontal charting. So far, sounds like a typical day at the office, right?

But now, what if the insurance company asks for consent forms, the doctor’s treatment notes, medical histories, patient payments ledgers, or lab slips? Should you comply? Of course you should, because you have nothing to hide.

Is there a way to make the audit process go more smoothly?

In my experience, sending the insurance company a narrative in advance can help minimize the chances of becoming the target of an audit. But sometimes, if a single claim payout is in excess of a certain dollar amount, it automatically triggers an audit. This leaves you with nothing but a delayed claim and having to take time out of your busy day to put together a whole presentation for a single patient claim, which can take minutes or hours.

What can you send prior to being the target of an insurance audit?

Here are the top three things to keep in mind when preparing a narrative for submission of a dental claim/audit.

1. If you can’t read your doctor’s handwriting, you can be sure the insurance company reps won’t be able to either. This is why the doctor should dictate the narrative as you type the information on letterhead. Be sure to explain what was done (although it’s already on the claim form), and most importantly, why it was done. Be sure to emphasize the “need” for treatment.
2.If the treatment was for cosmetic purposes, you can forget about getting paid. Be sure to focus on explaining why the treatment was necessary from a medical or dental standpoint. Explain the functional reasons using terminology the insurance company reps can understand. Be sure to point out what the desired prognosis is, and any complications the patient may have endured had the person not undergone such treatment.
3.If the treatment is not 100% visible on x-rays, you need to make sure your periodontal charting explains it. Be sure to indicate if the patient is suffering from recession, loss of attachment, bleeding on probing, pocket depths, bone loss, and other factors that could support the need for the treatment.

If you follow these steps with confidence, you’ll be a seasoned pro when handling an audit.

Kyle L. Summerford is a nationally recognized practice management guru, author, and lecturer. As founder and president of Summerford Solutions, Inc., he provides powerful information for dental staff members on his website, Kyle also serves as editorial director of Pennwell's Dental Office Manager Digest e-newsletter. He lectures extensively to dentists and their staff on topics such as insurance coding and billing, and useful practice management tips
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About the Author

Kyle L. Summerford | Editorial Director

Kyle L. Summerford is president of Summerford Solutions Inc. Being a dental office manager, dental practice consultant, and dental coding educator has enabled him to guide his company to provide services to dental practices and their staffs nationwide. Kyle has lectured at many CE events and academic institutions—Stony Brook University, New York City County Dental Society, and Georgia Regents University. He’s authored many Dental Coding with Kyle articles. He’s the founder of Dental Office Managers Facebook Community and Dental Manager Connect. Contact him at [email protected].