Insurance Company Audits

Audits from insurance companies and third party payers have become increasingly more common over the years. Some providers are randomly selected and others are selected through various profiling methods. These audits are performed for various reasons but are a method of showing state regulators that the patients are receiving quality care and also as a measure to prevent fraud or abuse.

Providers will usually receive a letter weeks in advance advising to prepare for an audit of charts for patients covered under that plan. Sometimes the company may provide a list of patients whose charts they would like to review, but this is not always the case. Auditors will typically want to review patient medical histories, dental histories, documentation of oral examinations, treatment notes, diagnosis, procedures completed, the outcome of each procedure and follow-up care. They may also check to for informed consent forms and that proper co-pays/co-insurances have been collected. There have also been cases when an auditor will be evaluating overall cleanliness, sterilization records, infection control protocols, emergency kits, and etc.

Although this can be a hassle, it is important that you comply with the request as it is within the rights of the insurance company to perform audits as necessary.