Insurance carriers can audit you!

July 1, 2004
Patients with insurance generally receive more complete treatment than those without.That's why many dentists agree to be providers for dental plans.

Carol Tekavec, RDH

Patients with insurance generally receive more complete treatment than those without.That's why many dentists agree to be providers for dental plans.Accepting insurance can involve a contract, such as a Delta network-provider contract, where the dentist agrees to certain stipulations about how Delta patients will be billed.It also can be apayment situation, where the dentist treats a patient who has insurance, regardless of whether or not the dentist accepts "assignment of benefits." But whether you are a contract provider or simply treat patients who have insurance, you need to know that insurance plans can audit charts of patient subscribers. What does this mean?

* You may receive a letter from a plan telling you to prepare for an audit of charts for patients with that insurance. Typically, you will be given several weeks' notice, and you may be able to select the time of the audit that works best for you.

* An auditor will come to your office, usually armed with a list of patients whose charts are to be reviewed.

Many dentists think that an insurance plan auditor has no right to look at patient records without the written consent of the patient. HIPAA — the Health Insurance Portability and Accountability Act — requirements specify that your patients' health information must be protected and kept private. However, insurance plans have the right to access information that they think is necessary to pay claims and fulfill their obligation to "police" the plan. Employers who purchase the plans and their employees — your patients — give them that right as part of accepting the plan in the first place. A separate, signed authorization to release information is not required. In fact, the ADA HIPAA Privacy Kit lists general provisions under which a health plan may obtain protected health information (PHI) from you for payment purposes. These include, but are not limited to:

1) Determining eligibility and adjudicating claims for patients.

2) Reviewing health-care services for medical (dental) necessity, coverage, justification of charges, and payment history,

3) Utilization review (how many procedures of a certain type a dentist performs).

Also, financial records, to match up with the patient charts — either paper or computer — and a patient's personal co-payments to the dentist may be reviewed.

Under HIPAA, dental insurance plans also are required to protect a patient's health information. Even so, every dental office should have, among other items, a written "Notice of Privacy Practices," where the office privacy policies are detailed, including this obligation to reveal information to insurance carriers, federal officials, and/or law enforcement. This should be provided to every patient. (To view a sample "Notice of Privacy Practices," visit our Web site.)

An auditor will be looking for various types of information, including instances where a patient, and therefore the plan, may have been billed outside of the parameters of the contract. For example, many plans set guidelines on services that are considered "all-inclusive." If a dentist bills D4249-Crown Lengthening, D2950-Core Buildup Including Pins, and D2750-Crown-Porcelain Fused to High- Noble Metal on the same day, many plans will only pay an all-inclusive, lump sum benefit. If the patient chart does not document details for the separation of the codes — such as D4249, "No. 19 presented with broken cusps on the mesial and distal, with caries extending subgingivally" or D2950, "More than 50 percent of the coronal tooth structure missing" — the carrier may request a refund and a credit for the patient's portion. The plan also may have a stipulation about when a crown may be billed — i.e., either the prep date or seat date.

Another example might be D4910-Periodontal Maintenance, where carriers are looking for documentation that the patient has had previous surgery or root-planing, and the D4910 includes documentation of probing depths, bleeding, furcations, recession, and mobility.

Detailed patient records are the best defense during an insurance audit. It is vital that the office maintains precise documentation.

Carol Tekavec, RDH, is the author of the Dental Insurance Coding Handbook Update CDT-4, co-designer of a dental chart and an informed consent booklet, and a national lecturer. Contact her at (800) 548-2164 or visit her Web site at

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