September 19, 2022

Understanding the Dental Plan Audit Process

Question: I’m being audited by a dental plan. It has done back several years and is demanding repayment of a lot of money. This has never happened to me before, and the process has been frustrating. It appears to me that this is not about my services, as no patients are complaining. Instead, the plan seems to have nitpicked my records and come up with any excuse it could find to ask for money back. Is this typical? What can you tell me about this process?

Answer: Your frustration is understandable. Our firm is currently representing several dentist clients who have been audited. The audits all begin with a letter from a plan/administrator requesting patient records. Once the records are produced and reviewed, the plan/administrator provides its audit results, including a demand that the dentists repay fees. The amount of the repayment sought varies – we have seen demands from a few thousand dollars to amounts in the six figures. The following are points dentists should understand about the audit process.

Timing. The plan/administrator will claim that each of its audit findings is a breach of your participation agreement. The statue of limitations on breach of contract claims is six years. This is why the plan/administrator typically audits records up to 6 years old.

It is not unusual for the plan/administrator to take a very long time to audit the records. A few months to a year or more is not unusual. When the audit results and a demand for repayment are provided, you typically are given only 30 days to respond, even when the audit results consist of a hundred or more pages of audit results. You should always request an extension. In our experience, reasonable requests are granted.

Not about dentistry. Most audit results have nothing to do with the appropriateness or quality of dental services. Instead, most audit results are allegations of recordkeeping deficiencies (such as illegible handwriting, use of abbreviations without including explanation, how a record has been corrected, missing signature, etc.) and errors in the claim filing process or your patient accounts (such as, the treading dentist is misidentified, there is submission prior to the completion of treatment, etc.). Plans/administrators routinely seek repayment in full for services that are appropriate and delivered in accordance with the standard of care when the audit reveals an error in the documentation of the service or the claim form.

Read the complete Q&A in the Journal of the Michigan Dental Association on page 20.

About the author:

Daniel J. Schulte answer questions about health care lawDaniel J. Schulte has more than 25 years of experience helping clients solve tough problems and capitalize on opportunities that require a blend of business and legal expertise. His practice focuses on addressing the legal, business, licensing, and regulatory challenges of health care professionals, organizations, and facilities. Dan understands how legal issues impact business objectives and, as a result, offers his clients practical, results-oriented advice. He is a Certified Public Accountant, former managing partner and current executive committee member of the firm. Dan also serves as co-chair of the firm’s Health Care Practice Group.

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Daniel J. Schulte

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Health Care Law