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Dental Coding Audits! Why are you waiting for a letter or call, stop it before!

Dental practices should periodically audit their coding to minimize compliance risks and optimize revenue. Many private payers including Medicaid’s Special Investigative Units (SIU’s) and the Department of Justice have had recently increased their focus on compliance. This comes at a time when children’s dentistry is now covered by the Affordable Care Act, otherwise known as “Obamacare.”

They are auditing dental practices with higher frequency to detect fraud, waste, and abuse. These compliance audits can lead to large recoupment payments from practices. In my experience, many practices that are caught for fraud aren’t purposefully committing criminal acts; they are merely victims of deficient coding or documentation knowledge. Periodic coding audits will help you find these deficiencies in your practice’s coding or documentation skills before a payer audit, giving you proper time to fix any issues.

Most dental providers never receive proper training in documentation and coding or delegate this task to untrained receptionists and team members. Our audits commonly uncover documentation deficiencies, which can inadvertently lead to lower payments and missed revenue as well as legal exposure. We often identify cases in which providers accurately document their services but aren’t coding for every procedure they perform, which can also lead to lower payments.

Years of experience in performing coding and auditing projects as part of dentists’ legal settlements with the Office of the Inspector General and The Department of Justice have given me a deep understanding of both the risks that practices face and the importance of prudent and early action. Accurate coding requires walking a fine line. Your practice wants to optimize revenue by accurately coding for each service rendered, while simultaneously ensuring that your coding and documentation aren’t opening the practice up to any compliance issues. The Coding Network’s dental audits will help you determine just how accurate your coding is and what effect it is having on your compliance risk and revenue cycle.

The outcome of a recent audit completed showed the following:

  1. Inconsistent Documentation Skills
  2. Documentation that did not match the procedure code used for billing
  3. ADA codes that were no longer available
  4. Overbilling of x-rays
  5. Payments from insurance company not matched by line item
  6. No updated with fees from each insurance company which gave overpayment status that really was office $$
  7. Non-Refunded money to both the patient and or the insurance company or to the office of record. (Big Legal Issue)
  8. X-rays that were taken and then not sent to insurance for payments at first billing cycle

This recent audit showed that all the above issues led to the company losing a large amount of money. Additionally, the following amounts of money are to be paid back:

  1. Paying back GHI Dental $8,000.00 in the overpayments for X-rays that were taken and were overpaid.
  2. Cigna has also asked for a refund of $2500.00 since they paid on a patient that was not seen in any of the offices that were audited. An agreement stating that that was an oversight on the billing department for this claim must be completed.

The following are the conditions set forth by Medicaid:

  1. A 1-year probation on all claims being paid
  2. Staying on track for the accepted plan of paying back the $33,000.00 plus penalties.
    1. For the next year they will take out of your payments monthly until it is paid.
    2. You are required to submit a monthly report and keep the compliance manager on track with outside compliance for one year.

In closing:

  • The total amount being paid back is over $50,000.00 at this time.
  • Our audit showed another $15,000.00 spread through the organization of lost income from improper billing, that we can work thru for the next mouth.
  • Currently documentation is the priority, with SOAP notes, that include the full treatment, diagnostic reason for treatment, and the outcome of treatment.
  • Training with all providers and assistants is necessary in order to achieve the outcome for success.

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