Simple corrections to prevent fraud and insurance audits

I have lectured and consulted full-time for the last 21 years about dental insurance and preventing dental insurance fraud. A great deal of this time has been spent defending dentists against insurance companies, state audits, and federal audits. If the defendant dentists had simply followed some basic rules and protocols, I would be a lot less busy in my consulting and defense capacity.

Very few dentists read their state dental practice act. It governs everything they do every day.
Fewer than 10% of dentists read the insurance contracts they sign or the provider manuals they’re given when they participate with insurance companies.
If a dentist is a Medicaid provider, they must read and understand the contracts and user manuals for their state, independent of their state’s dental practice act. What is legal in one state may be considered fraud in another.
Most dentists lack knowledge regarding what is legally required to be in the written patient treatment record.
Most dentists lack knowledge concerning the documentation required under PPO contracts and the federal law concerning Medicaid.
Dental malpractice insurance carriers report that incomplete and error-laden records are the top challenges in malpractice suits brought against dentists.

In 2019, the following explanations for denial were commonly cited by UPICs (unified program integrity contractors) such as DentaQuest and Delta Dental.

Failure to sign progress notes, either electronically or by hand

A dentist not properly signing a dental progress note, either electronically or handwritten, is not a mere technical deficiency. By law, the Centers for Medicare & Medicaid Services (CMS) contractors such as UPICs are actively denying dental claims if the associated progress note has not been signed by the rendering dentist. As set out in the Medicaid Program Integrity Manual, the regulation states, “unsigned entries” (referring to electronic and handwritten) “shall be excluded from consideration when performing [a] medical review.”

Similarly, private dental payers (insurance companies) have denied claims that were not supported by signed progress notes and/or orders. As a final point, most state dental practice acts include specific requirements mandating that progress notes, orders, and treatment records be signed by the licensed dental professional who performed the service.

Here are more examples of problems in the written guidelines that must be understood by the billing dentist to prevent fraud, audit, and denial of service:

Examples from a Delta Dental contract

“The information contained in this procedure manual is intended as a resource for you and your staff. It lists our standard administrative guidelines for claims processing based on the terms of the members subscriber’s certificate. Pediatric CDT guidelines put in place in response to the Affordable Care Act are described in red italics when covered. In all cases, including Total Choice PPO, specific group/individual contract provisions, limitations, and exclusions take precedence. Also, some employers customize benefits, meaning there may be variation in the services covered, patient coinsurance rates, deductible figures, plan year maximum, out-of-pocket maximum, and out-of-network fee schedule.

General policies: All services provided to covered members are subject to the following general policies. There are no grace periods for any time limitations.”

This “time and grace period” issue is covered in almost all provider manuals.
A good example of this is billing and payment for the second prophy for a given 12-month period. The language states either once every six months or twice a year. This issue came up frequently when I served as a chief dental consultant for an insurance company.
The answer is that six months or anything over six months gets paid. Five months and 29 days is denied. The company is simply following the contract language based on the request of the employer paying the premiums.

Why are some crowns denied?

Following are examples from a Delta Dental contract. Remember that each Delta branch can have different guidelines.

“Anterior teeth: Must show fracture or decay to the crown of the tooth and which involves four or more tooth surfaces including loss of one incisal angle. At least 50 % of the incisal angle must require replacement due to decay or fracture. There must be large existing restorations involving both mesial and distal surfaces, encompassing at least 50% of tooth structure that requires replacement due to decay or fracture. When a root canal was performed on an anterior tooth and the endodontic access was minimal the tooth does not qualify for a post and core, buildup, or a crown.

Posterior teeth: To qualify for benefits, premolars must show fracture or decay to the crown of the tooth and involve three or more tooth surfaces including one cusp, and molars must show fracture or decay to the crown of the tooth, which involves four or more tooth surfaces including two or more cusps. Some of these issues must be present: large area of decay on an unrestored tooth; extensive recurrent decay on an additional surface of a previously restored tooth; prior endodontic treatment; evidence of cuspal fracture, proof of cuspal fracture with a narrative plus x-ray (if apparent on film).”

The reason for denial

Crowns, inlays, and onlays are covered only when the tooth is extensively decayed and/or has a complete cusp fracture (not craze lines) and cannot be restored by an amalgam (silver filling) or a composite restoration (filling). Crown benefits are not available for teeth that may fracture in the future. The key word here is “may.” The tooth is not fractured and missing a cusp at this time.

From these examples I hope that readers get a sense of how the system works. This material should also be used to educate your patients.

Editor's note: This article appeared in the June 2022 print edition of Dental Economics magazine. Dentists in North America are eligible for a complimentary print subscription. Sign up here.