Running a successful dental practice means balancing excellent patient care with managing the business side of things. However, one area that often causes stress for practices is the risk of insurance audits. Insurance companies routinely review claims to ensure compliance, accuracy, and adherence to coding standards. While this process is standard, certain issues can make your practice a target. Understanding the red flags that trigger insurance audits can help you protect your revenue and maintain compliance.
Unusual Billing Patterns
Insurance companies monitor billing trends across all providers. If your practice consistently bills for a higher volume of certain procedures compared to your peers, it may raise questions. Excessive claims for crowns, periodontal procedures, or scaling and root planing can trigger insurance audits. While legitimate patient needs vary, consistently out-of-range numbers can put your practice under scrutiny.
Upcoding and Coding Errors
Submitting claims with codes for more expensive procedures than were performed, whether intentional or accidental, is a major red flag. For example, coding a simple extraction as a surgical one or misrepresenting a filling as a crown will attract attention. Even honest mistakes in CDT code usage can prompt insurance audits, so coding accuracy is essential.
Missing or Insufficient Documentation
Every claim submitted must be supported by complete documentation. Lack of detailed treatment notes, missing radiographs, or vague charting are common triggers for insurance audits. If your practice cannot prove that a billed procedure was necessary and performed, insurers may deny the claim and request repayment.
High Frequency of Some Treatments
If your practice regularly performs treatments like scaling and root planing, bitewing X-rays, or replacement crowns at a rate much higher than average, this may look suspicious. Insurance carriers expect patterns within certain ranges, and deviations often lead to insurance audits.
Billing for Non-Covered Services
Submitting claims for services that aren’t covered by a patient’s policy, or attempting to disguise them as covered treatments, can result in immediate red flags. Even if it was accidental, repeated errors in this area often lead to insurance audits.
Patient Complaints
Sometimes audits are triggered not by data patterns but by patients. If a patient questions a charge, disputes a treatment, or files a complaint with their insurer, the company may decide to review multiple claims from your practice. A single complaint can open the door to extensive insurance audits.
Too Much Narrative
While narratives are sometimes necessary to explain unusual circumstances, relying heavily on them instead of proper documentation can appear suspicious. Frequent use of narratives without strong supporting evidence often leads insurers to initiate insurance audits.
Don’t Fear Your Finances with APEX Reimbursement Specialists
If you are ready to get the most out of your practice or learn more about reimbursement negotiation, APEX Reimbursement Specialists is here to help. Contact our team today by calling (410) 710-6005. We look forward to working with you to make your practice a more profitable place.