Liles Parker PLLC
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Washington, DC | Houston, TX
San Antonio, TX | Baton Rouge, LA

We Defend Healthcare Providers Nationwide in Audits & Investigations

As Medicaid RAC Dental Audits Increases, so is the Importance of Dental Compliance.

Medicaid RAC Dental Audits are Increasing. Is Your Practice Compliant?(April 20, 2012): As previously reported, Medicaid RAC contracts have been awarded in 26 states, and more are being awarded each day. As Medicaid RAC dental audits increase, it is essential that dentists and orthodontists, especially those who treat children, fully comply with Medicaid’s documentation, medical necessity, coverage and payment rules.  As a first step, we recommend that you develop and implement an effective compliance program for your dental practice.



I.  Why is Medicaid RAC Dental Compliance So Important?

Under the Affordable Care Act (the law currently being reviewed by the Supreme Court), States must contract with Medicaid RACs to audit claims under the Medicaid program and recoup any identified overpayments. While the rules, initially proposed in November 2010 and finalized in September 2011, have been delayed several times by the Centers for Medicare & Medicaid Services (CMS), several States have consummated contracts with Medicaid RACs. We expect the number of States with active Medicaid RAC dental audits to increase in the future.

Because the Medicare and Medicaid programs – and who they cover – vary greatly, Medicaid RACs will likely have a very different set of audit targets. These targets may include dentists and dental practices, which have otherwise been immune to these types of audits in the past. As a consequence, dentists and orthodontists should review the medical necessity of their procedures as well as the documentation used to support such procedures with a critical eye – RAC auditors will be doing the same.

II.  Steps to Implement an Effective Dental Compliance Program:

The most effective method overall to enhance your dental practice’s compliance with applicable laws and regulations is to implement an effective dental Compliance Plan. In addition, your practice should conduct a gap analysis of both your business and clinical operations to identify any deficiencies and possible corrective actions that need to be completed. We recommend that a gap analysis include the following four steps:

  1. Identify applicable legal and ethical standards to be achieved and maintained, including Federal and state statutory regulatory requirements, coding and billing requirements for claims, and optimum documentation practices.
  2. Conduct an audit of the entity’s current coding activities, billing practices, operations and business practices. Review documentation, medical necessity of services, contracts, leases, and other arrangements.
  3. Assess where coding, billing, operations, and billing practices fall short. This represents the “gap” that must be filled.
  4. Continually monitor applicable standards so that any changes can be readily identified and any necessary corrective action can be taken.  Additionally, periodically review the provider’s actual baseline and ensure that the provider continues to meet the applicable performance standards.

III.  Conclusion:

There’s no question that dental compliance is going to be critical for dental and orthodontic offices in the future. Rather, the question is how your practice will respond and implement an effective program. Remember – a “Model Compliance Plan” downloaded from the internet or disseminated from a professional association is just that – a model.  A Dental Compliance Plan that has not been personalized to your practice will likely be little help to you and your staff.  It is essential that you engage a qualified law firm to conduct a “Gap Analysis” of your practice.  Once practice-specific risks are identified, mechanisms will be set up to prevent those “unique” risks from reoccurring.  Ultimately, an effective Dental Compliance Plan is like a flu shot – it cannot completely prevent you from catching the flu, but if you have endured the shot, the flu symptoms should not be that bad.

Healthcare LawyerLiles Parker is a full-service health law firm focusing on regulatory compliance and provider representation. Our attorneys are highly skilled in designing and implementing effective Compliance Plans for dental and orthodontic practices, as well as for other health care providers. Moreover, our attorneys are experienced in handling an array of complex health law matters, including the appeal of alleged overpayments to Medicaid. For more information on how we can assist you in developing an effective dental compliance plan, call Robert W. Liles, Esq. Robert is Managing Partner at the Firm and can be reached at: 1 (800) 475-1906. Please call him today for a free consultation.

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