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Why am I being audited?

Updated:
May 2019
Topic:
Fraud/Audits

Payers indicate that most audits are random; however, experience suggests random audits are seldom random.  It’s expensive and time consuming for a payer to conduct audits.  As a result, payers generally focus on the statistical and actuarial information to help focus audits on individuals and/or practices that are different in their submission patterns from other dentists/practices in that network, state, area, or other defined group.  Each practice and dentist is “profiled” by payers for forensic review of submission histories to see how they compare dentist to dentist and practice to practice for trends that set that dentist/practice apart from others in the group reviewed.  Many payers allow their submission data to be pooled with other payers’ submission data to get a larger statically significant sample to validate the findings.  There are companies that tabulate the combined submission information from multiple payers in order to provide norms for all claims’ submissions information across the nation.  This information helps to establish, for example, the expected percentages of all restorations a provider placed.  This data provides how the average percentage of one, two, three, or four surface restorations would be expected by a general dentist in Charlotte, NC for the first quarter of 2019 as an example.  Dr “Average” provides the same percentage of one surface composite restorations as does all the other dentists in the same zip code, state, region, or in the nation.  That doctor who provides, statically, 2 standard deviations more for one surface composite restorations than all the other dentists reviewed in that geographical area is at higher risk of an audit than one who provides 1 standard deviation fewer than all the other dentists in that geographical area. 

This is not to say that the doctor who is doing more one surface restorations than all the other dentists in that sample is doing anything wrong, but it does suggest that the doctor is at higher risk of audit and that the dentist should be prepared for the audit with proper documentation to prove medical/dental necessity for the care provided.  Documentation can be obtained by written support or by other subjective documentation like radiographs, photographs, or other diagnostic tools(Diagnodent®, etc.).

Something else that may increase the potential for an audit is patient or another provider complaint.  It would be unlikely that a single patient complaint to a payer would trigger an audit (unless there was flagrant misconduct with irrefutable evidence).   But, multiple patient complaints about a practice or a dentist may trigger an investigation that could lead to an audit.  A complaint from another dentist would carry more weight and would generally lead to a probable investigation, if not an audit.

In order to reduce the risk of audit, be compliant with all rules, regulations, and restrictions established by the plan, be careful to meet the standard of care and document appropriately.  If you are compliant, vigilant for mistakes, and prepared, audits are not as daunting. Simply put, audits are a fact of life in today’s dental world.

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D6980

REVISED CODE

Fixed Partial Denture Repair

A single cast metal crown restoration that is retained, supported and stablized by an abutment on an implant; may be screw retained or cemented.

NOTE: May be orthodontic related