As part of a contractual commitment the dental benefit plans  have with their consumers (employer groups and their employees), the plans are  required to have a claims utilization review and audit process. State  regulators, such as the Department of Managed Health Care and Department of  Insurance, also have requirements for the dental benefit plans to have  antifraud policies and procedures in place for all insurers.

CDA is receiving an increasing number of calls about these types  of reviews and audits as dental benefit plans continue to perform more of them.  Utilization review can affect dentists who treat patients covered by a dental  benefit plan; therefore, it is important that dentists understand the complete utilization  review process since it can result in an audit of a dentist's patient records. The  utilization review process is designed to ensure that dental procedures  reported on behalf of plan enrollees, by their dental office, are rendered  consistent within the provisions of the benefit plan and the participating  provider agreement.

What to  expect during the utilization review process

The utilization review process begins with a post-payment  review that may result in identification of a potential concern. According to  the benefit plans, the concern is generally identified when there is a pattern  of over- or under-utilization of services identified through statistical  analysis of peer comparison, utilization data and/or dentist practice patterns.  It can also occur because an inquiry or complaint was received from a patient  or another dentist, and even from discrepancies noted during claims processing.

Ultimately, the benefit plan is looking to identify those dentists who could  potentially be providing services outside the community standard or the benefit  plan's guidelines. The utilization review is also designed to identify  fraudulent billing patterns.

Types  of issues the plans are looking for:

  • Billing       for services not rendered.
  • Intentional       misreporting of procedure, date of services, identity of the dentist or       identity of the patient.
  • Deliberate       performance of unnecessary services.
  • Alteration       of patient record.
  • Reporting       a more expensive procedure than was actually rendered (upcoding).

Professional  review/audit of patient records

Based upon the results of the analysis, the dental plan may  decide it is necessary to review a sample of patient records to evaluate a  dentist's reporting pattern. The plan usually selects the patient record list for  review based upon the procedures it has identified as a concern. The records  may be requested from the dentist or an on-site review may be conducted in the  dentist's office. The number of patient records requested for review can vary  from five to 25, possibly more. Many dentists find the process of copying  records to be cumbersome and time-consuming.

Contracted providers are likely required to comply with  these types of requests, according to their provider agreement with the plan. However,  if a dentist is not contracted with the plan, the dentist is not contractually  obligated to comply with the plan's policies and procedures.

Generally, the dentist is notified by letter, which will include  relevant guidelines, a list of requested patient records or information announcing  the on-site review of records. Providers should be aware that there is typically  a specific timeframe to respond to the request. Normally, the letter will include  contact information for a dental plan representative who can discuss and answer  questions about the patient record review and even grant an extension of time.  Dentists should not be afraid to contact the plan representative to discuss  clinical or policy-related questions, as well as to better understand what to  expect during the utilization review process.

The dental plan will review the records, which usually involves  an administrative person and a licensed dentist for clinical perspective. The  entire record, including treatment notes, X-rays and all diagnostic materials,  will be reviewed and compared to claims submitted for payment to the dental  plan for services rendered by the dentist. This review will determine whether  the records adequately document the services reported on the submitted claims  to the dental plan.

Reviewing  results

Upon completion of the record review, the findings should be  provided to the dentist. If any discrepancies are identified, a detailed report  is provided. Corrective actions may be required; if the discrepancies found resulted  in an overpayment, the plan may calculate and request recoupment from the  dentist.

CDA members who have experienced recoupments reported that  it has been beneficial to appeal the findings that resulted in recoupment.  While this may be time-consuming, the benefit plans have made considerations  and some members have seen their recoupments significantly reduced. In  addition, we have learned that benefit plans will often negotiate the  recoupment amount, making it beneficial to have a conversation with the  reviewing dentist or administrative contact person and request a lower  recoupment amount.

Prepayment  and special claims review

If the dental plan identifies problems of a repetitive  nature during record review, a dentist may be placed on a special claims and/or  prepayment monitoring. This type of monitoring may require the dentist to  submit additional supporting documentation beyond the standard plan policy when  submitting claims or requests for predetermination. The monitoring can last for  several months, and a dentist may be terminated from the plan if improvement is  not seen.

Increasingly, CDA Practice Support has heard from members who  have gone through the utilization review process and have reported findings of  improper or inadequate documentation in their patient records, ultimately  resulting in negative actions toward the dentist.

Tips  for accurate dental record

  • Note the site of service.
  • Documentation for each service performed should include the reason, any relevant history, physical examination findings, assessment, clinical impressions,       diagnosis, treatment plan, date and treating dentist.
  • Documentation should support appropriateness of billing.
  • Dental record should be complete and legible.

Record-keeping is an essential part of a dental practice,  and while a practice may never have a review like this, providers should make  sure records always support the treatment rendered. It is always recommended to  bill for what is done, not what the benefit plan will pay for, and to ensure  treatment records are an accurate reflection of sevices billed.

Dentists who need assistance with a utilization review or  chart audit can contact CDA Practice Support at 800.232.7645800.232.7645 FREE.

Patient Record-Audit Checklist

  • Comply only if you are contracted with the benefit plan
  • Provide completed quality copies of the chart
  • Provide good-quality diagnostic radiographs
  • Be sure to keep a diagnostic copy of radiographs for your records
    • Benefit plans do not return radiographs
  • If audit results in recoupment, utilize your appeal rights
  • Request peer-to-peer conversation with the reviewing dental consultant
  • Negotiate the  recoupment amount

http://www.cda.org/news-events/understanding-utilization-review-and-audits-by-benefit-plans