Payer Audits: What you need to know
Posted February 7, 2017 by Danielle H
With tens of billions in financial losses due to health care fraud annually (according to the National Health Care Anti-Fraud Association), third party payers are taking action. In an attempt to prevent abuse of the payment system, payers are now routinely conducting audits of health care providers. This article will help you understand how payers choose providers to audit and how you can prepare your practice.
Why me?
For insurance payers, the audit process often begins by looking at a specific dental plan. Payers analyze procedures submitted across all providers and look for inconsistencies. Auditors look for unusual charges and/or providers that submit a particular charge at an atypical frequency. As the payer looks closer into a particular provider, they will examine data relating to average cost per claim and average cost per person. Once the auditor has identified providers with the greatest discrepancies, they choose to audit one or multiple providers.
I’m being audited. What now?
Most dental practices will be notified of an audit by telephone or mail. In many cases, the third-party payer will arrange a day and time for the audit. Upon receiving a call like this, ask the payer representative why you are being audited. Likely, they won’t share details, but any information you obtain could help you prepare.
Plan to clear your schedule or significantly reduce your number of patients on the day the payer representative arrives. Meet with your entire team ahead of time to inform them of what is going on and what is expected of them. A primary focus of an auditor is to review patient files that support claims that were submitted. The auditor will request information from specific patient records and should be permitted only to view the records of the patients covered under their plans. HIPAA privacy laws do not allow payers to view the patient information for those that are nonmembers of their plans (or former members). Participating providers are typically left without recourse when the story told by the patient record doesn’t support the necessity of the treatment provided.
Preventative Measures
With dental payer audits becoming more routine, preparing your practice for a potential audit is increasingly important. For each insurance company that a practice participates with, the dentist and insurance coordinator should review the payer contracts annually. Designate a safe place to keep these items so they are easy to reference when needed. Next, review a report of the most commonly used procedure codes in your practice. Use Practice Booster to review these codes for accuracy. Are you submitting these codes under the proper circumstances? A Practice Booster subscription can help you stay on top of the latest information related to coding and insurance. Lastly, examine the documentation processes you have in place. Do your progress notes tell the entire story? What documents help support your necessity for treatment in any situation? Take time to review your processes with your team regularly. If you want to see what Practice Booster can do to help reduce your risk, contact XLDent for a special offer today.
Now that we’ve explored risk management as it pertains to your clinical practices, infrastructure, and insurance, stay tuned next week as we look at malpractice and how to handle risky patients.
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