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Dear Doctor,
Periodically we analyze claims to determine the accuracy of the codes submitted. At this time we have noticed unusual patterns in your practice’s claim submissions and request you provide copies of the patient records listed below. Thank you for your cooperation
Sincerely,
Utilization Review Department
The typical response: “Audit! Audit! But I did not do anything wrong!”
Perhaps there has been no wrong doing by the practice, but in some way the practice has attracted the attention of either an insurance company. Of the phone calls I received last year from offices receiving a letter from an insurance company, two were pediatric dentists, several general dentists, and an orthodontist! Most of these dentists had submitted the requested records months prior to contacting me and were now in receipt of a refund request. The requests ranged from $18,000 to $500,000.
Why and How
There are no “routine” audits or review, so why were these practices audited? The most common reason is that the frequency of certain CDT codes submitted is far beyond the peer norm for those reported codes. The insurance company’s computer easily identifies an unusual pattern of claims, an outlier, if you will. Simple utilization of reports identify the practices submitting the highest number of claims of specific codes, or the highest frequency of a treatment per a given number of patients. If the norm for a treatment is 30 per 100 patients in your state, but your practice’s frequency if 50 per 100 patients, this information jumps out as potential overutilization.
For example, periapical radiographs are routinely exposed in conjunction with periodic oral evaluations. This is a low dollar procedure until it is multiplied thousands of times. It is, of course, a beneficial diagnostic procedure when medically necessary and the findings re documented in the patient record. Without both a diagnosis and documented findings by the dentist, there is no reason to take a radiograph

If the patient record indicates the patient had sensitivity, recent trauma, or other issues, and the chart is documented with this information, then there is not a problem.