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of claim denials are overturned
improvement in net patient revenue
of claims are collected within 90 days or less
clean claims rate
average reduction in AR days

Dental Group Billing Audits

Samoya Skeete
Samoya M. Skeete
Certified Coder and Healthcare Auditor
Dental Group Billing Audit Team Lead
Chris Anderson
Chris Anderson
Chief Compliance Officer
Dental Group Billing Audit Team Lead

The medical billing and coding process involves translating medical diagnoses and procedures into billable codes and then submitting those codes to payers, such as private health insurance providers and federal and state programs, namely Medicare and Medicaid. That’s the definition provided by the American Academy of Professional Coders (AAPC), the largest, most trusted medical coding training and certification organization in the U.S. Long story short, medical billing and coding enables individual healthcare providers and medical facilities to receive payment for services rendered. Whether it’s a large or small medical facility, it pays to have medical billing and coding done correctly and as promptly as possible. Failing to do so can lead to late and even nonreceipt of payments, not to mention coding compliance issues, which some might argue is an even worse consequence.

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Dr. Stephen Taylor

DOL Consultant

Roger Bach

Former Special Agent (OIG)

Chris Quick

Former Special Agent

Kevin Smith

Former Assistant Regional Inspector General

Michael Koslow

Former Supervisory Special Agent (DOD-OIG)

James Hunt

Former Special Agent-in-Charge (DEA)

What Is Billing and Coding Compliance?

Before delving into the consequences of being out of compliance when it comes to billing and coding, let’s take a moment to familiarize ourselves with what such compliance means. From a coding standpoint, compliance means ensuring the coding of diagnoses, procedures, and data is congruent with established coding rules, laws, and guidelines. Such compliance mitigates fraud and abuse by healthcare providers. It also contributes to the following:

  • A much more streamlined revenue cycle
  • Improved adherence when it comes to government healthcare regulations
  • Fewer claim disputes and denials

Medical billing and coding began in 17th Century England, which is how the world became acquainted with the International Classification of Diseases, Ninth Revision (ICD-9) codes. Although ICD-9s got the proverbial wheel rolling, in 2015, ICD-10s replaced them. There have also been other coding changes, but medical billing and coding, as a whole, is likely here to stay. To ensure the proper use of these codes by all healthcare providers, billing and coding compliance audits are necessary.

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What Triggers a Billing and Coding Compliance Audit?

According to an article published by the Physicians Advocacy Institute (PAI), a nonprofit that supports physicians through research, education, and policy advocacy, no healthcare provider or medical practice is impervious to a billing and coding compliance audit. Multiple things can increase the likelihood of being subjected to one, including using billing codes that do not align with a patient’s diagnosis or treatment. In some cases, compliance audits can stem from information from a whistleblower. They can also arise from data mining of insurance claims, a common practice among many leading health insurance providers. Since we are on the topic, it is worth noting that some healthcare providers are targeted for these audits more than others, dentists being among them.

Billing and Coding Compliance Audits: What Dentists Should Know About Medicare and Medicaid

Dental group billing audits are becoming increasingly prevalent. Studies show that after the passing of the Affordable Care Act, the number of adults qualifying for Medicaid dental benefits increased significantly. That increase led to an expansion of covered Medicaid dental services, which spelled higher operating costs. In response, Medicaid started looking into things that were seldom ever on their radar before, and that gave rise to more billing and coding compliance audits, many of which revealed that a large contingent of dentists engaged in the following when it came to Medicaid patients:

  • Billing for procedures never performed
  • Billing for unnecessary procedures,
  • Substandard or abusive patient care
  • Substandard work
  • The improper prescribing of opioid-based drugs

As far as Medicare is concerned, dental group billing audits resulting from non-compliance usually involve some form of fraud. A joint investigation comprising the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services Office of Inspector General (OIG) found that a large percentage of dental offices across the U.S. engaged in one or more of the following when billing Medicare:

  • Failing to sign progress notes
  • Submitting claims from unlicensed or excluded dentists
  • Misrepresenting the provider of dental services rendered
  • Falsifying dates on submitted claims to get around time limitations, calendar year maximums, or both
  • Failing to demonstrate medical necessity when necessary
  • Failing to secure dental treatment plans, consent forms, and patient dental records

While other things may or may not trigger a dental group billing audit, discrepancies and outright fraud involving Medicaid or Medicare will do the trick every time, especially since both organizations are working hard to reduce fraud and lower operating costs. The same more or less applies to private dental insurance companies.

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Why It Makes Sense To Hire a Dental Billing Professional

Billing errors can result in a loss of revenue for your dental practice. Further, they can cause reputational damage and increase your chances of being audited by a government or private payer. Hiring a professional dental billing services company to handle your billing obligations can lower your chances of being confronted with such problems. Doing so also enables you to put more time and effort into caring for your patients. Whether they are working with a small dental practice or a larger one with multiple locations, professional dental billing services companies help clients become billing and coding compliant via the following:

  • Conducting internal audits of Medicare and Medicaid patient charts
  • Pointing out poor billing practices and identifying missed charges
  • Evaluating claim denials for possible appeals
  • Exposing Potential Liability Issues

While these various things are helpful, dental billing services companies do much more for their valued clients. They also teach them how to identify and resolve common billing errors before a claim gets generated and sent to a payer. Being this proactive can go a long way toward forestalling a potential billing and coding compliance audit. Some of the billing errors these companies help clients identify and resolve include

Not verifying patient eligibility – Some dentists and dental offices are so excited to help patients improve their oral health and achieve a beautiful smile that they fail to verify patient eligibility. While such enthusiasm for the patient is commendable, failing to verify insurance information can lead to payment delays or nonreceipt of payment. The same applies to prior authorizations. Some dental procedures must be pre-approved by a patient’s dental insurance provider, which means the dental office must submit documentation and await approval before performing a particular dental procedure.

Bundling errors – Some dental offices will perform two or more dental procedures on a patient and submit a claim for reimbursement for the one covered at a lower cost based on the patient’s dental insurance policy. Sometimes, bundling benefits the patient by reducing the total cost of their dental visit, which is helpful if they have a high co-payment. But sometimes, bundling can leave a dental office holding the proverbial bag, meaning they don’t receive the compensation they should have received from the patient’s insurance provider.

Coding mistakes – Submitting a claim for reimbursement with the wrong diagnosis code is a surefire way to receive a denial from a payer. And submitting too many claims with such coding mistakes to some payers can eventually result in a billing and coding compliance audit. That said, it pays to double-check and even triple-check what codes you’re using when submitting a claim for reimbursement. It also pays to stay on top of any coding changes. After all, submitting an old code when there is a new one, as in the case of ICD-9s and ICD-10s, can also cause coding mistakes and up the ante for potential audits.

Missing or incorrect patient data – Submitting a claim for reimbursement to a government or private payer with incorrect or missing patient data can lead to a quick denial. That information can pertain to the patient’s name, date of birth, and insurance provider, among other things.

In summary, dental billing and coding is something every dentist and dental practice should want to take seriously. After all, billing and coding mistakes can be costly in more ways than one. For more information on billing and coding compliance audits and how to lower your chances of being subjected to one, consider scheduling a consultation with one of our friendly and knowledgeable associates today.