Dental Audits and Reviews

Dental offices must have appropriate safeguards in place to ensure they are prepared for Federal, state, and/or private payor audits and reviews.

Dental offices may bill to Medicare under a few specific situations and these payments receive strict scrutiny during a Zone Program Integrity Contractor (ZPIC) or Recovery Audit Contractor (RAC) audit. In addition, dental offices are subject to Medicaid Integrity Contractor (MIC) or Medicaid Recovery Audit Contractors (MRACs), as well as federal and state Offices of Inspector Generals (OIG) reviews. Dentists should be aware of audit letters from these contractors, which are sometimes followed by an on-site visit. These audit letters have a tendency to be very broad and do not usually give the dentist any idea of what types of service are under review.

Liles Parker attorneys have developed a seven-point checklist to determine the appropriateness of a claim and its documentation. Contractor audits will likely utilize a similar evaluation.

Element 1: Medical Necessity of Dental Services Provided. Dental documentation must clearly demonstrate that services provided were reasonable and necessary. This may sound simple, but this is actually an issue that is often in dispute on appeal.

Element 2: Were the Dental Services Actually Provided? Documentation must show, in addition to medical necessity, that the services were actually rendered.

Element 3: Were the Dental Services "Tainted" for any Reason? This element asks whether the dental services violated a law like the Anti-Kickback Statute or the False Claims Act.

Element 4: Do the Dental Services Qualify for Coverage? Even if the dental services were medically necessary, they may not necessarily qualify for coverage and payment. Coverage can change from year to year and from payor to payor.

Element 5: Is your Documentation of the Dental Services Complete? Dentists must ensure that their documentation complies with all regulations and guidance for particular dental claims issued by CMS, the Medicare Administrative Contractor (MAC), and Medicaid contractors handling your zone.

Element 6: Are your Dental Services Properly Coded? Make sure your staff is properly trained on the Code on Dental Procedures and Nomenclature or "CDT" code book in addition to the CPT®, HCPSC II, and ICD-9CM (ICD-10CM). It is still possible to make a coding mistake even if you have met all of the previous elements.

Element 7: Did you Bill for the Dental Services Rendered Correctly? Just like coding, it is also easy to make a billing error and it is critical to ensure that your staff has properly billed for the dental services rendered to the patient.

Dentists should review and update their documentation procedures to ensure that a third party can easily identify why certain services were rendered and that these procedures were properly coded and billed in compliance with the applicable Medicare and Medicaid policies. Dentists should also implement Compliance Plans and train staff on how to respond to an audit.

Liles Parker attorneys have a wealth of experience with dental audits and reviews. We are able to prepare your office for an audit, assist with an audit or review, or counsel your office through an appeal. Call for a free consultation: 1 (800) 475-1906.

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