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By Arlene Furlong

What's an easy way to provoke frustration, anger, indignation and even panic in many dentists?

Send a letter that begins something like this:

"A recent analysis of your claims submissions disclosed that you report one (dental procedure inserted here) at a frequency rate that significantly exceeds that of your peers."

Or like this:

"We've selected your practice for an audit. To assist us in evaluating the appropriateness of your reporting, please provide copies of the following for patients on the attached list."

Or something that can be summed up this way:

"We're requesting a refund of some $200,000 dollars in already-paid reimbursements."

"When it comes to a retrospective claim audit, it's pretty common for a dentist's first question to be, ‘How dare they?' " says Dr. Michael Perpich.

A practicing dentist, Dr. Perpich now also provides consulting services for dentists undergoing such audits. He reviewed claims from a third-party payer's point of view for 11 years while working for Delta Dental Plan of Minnesota.

Depending on the insurer's policies and contracts, dentists might be required to refund claim payments to insurance companies for claims already paid. Depending on the dental procedure under review, insurers might require substantiation for submitted claims, including lab bills, periodontal charting, radiographs, financial ledgers, documentation of insurance and patient payments and dental records including progress notes.

"Most dentists don't have the opportunity to look at anyone's reporting practices but their own so it's difficult for them to see things a different way," says Dr. Perpich. "I help them do that and sometimes it becomes pretty obvious to dentists why some claims are audited."

Dr. Perpich says most dentists who have gone through an audit become much better at providing notes in patient charts that detail why specific treatments were provided.

"Dentists are very vulnerable when they're audited for high utilization and can't justify why they've done what they've done," he says.

Two and one-half years after being audited by United Concordia, Dr. Paul K. Seo of Honolulu was required to include his rationale for providing radiographs and a copy of the progress notes with each radiograph claim he submitted. If a claim was denied, he disputed the decision and was occasionally successful in reversing wrongful determinations.

Dr. Seo believes that his maintaining tenacity and providing clear documentation had an effect, as a May review found that the majority of the services he provided had been consistently approved and UCCI freed him from requirements to routinely request predetermination when filing radiograph claims.

Some dentists have found that reviewing each chart can reduce the refund request significantly. "If you don't appeal their decisions, you're accepting them," says Dr. Seo.

While Dr. Seo's results might sound like good news, a May 9, 2005, UCCI letter to Dr. Seo also suggests a post-payment review may be conducted in the future. It says that if the results of that review are unfavorable, a refund may be requested and the prepayment flag reinstated.

United Concordia typically sends a letter to dentists whose frequency of reporting a particular service exceeds that of other dentists working within the same specialty in the state according to its statistical analysis. It asks dentists to review their office policy and tells them to expect a follow-up review on the procedures deemed over-reported in 12 months.

Thomas Harbold, senior vice president of UCCI's TRICARE dental program, says that although recovery of overpayments is no longer a primary focus of its audits, there are still occasional circumstances where UCCI pursues a refund.

"What we will try to do is apprise the dentist of our findings and see if some type of corrective action by the office occurs, or we may try to preclude additional overpayments from going out the door," says Mr. Harbold. "Claims from that particular doctor may not go through as a routine process but get moved to a special review area requiring dentists to prove payment eligibility before being reimbursed."

A dentist who provides treatment in a low-income area says a major payer audited submitted claims a few years ago for surgical extractions and later was reimbursed some $2,000 after the provider defended the work. In 2005 the dentist was audited again, this time for scaling and planing, surgical extractions and molar root canals. The dentist says the payer required substantiation to determine necessity and payment eligibility for the procedures in question.

"That kind of hassle and stress over your head just isn't worth it," the dentist who wishes to remain anonymous told ADA News. "The patient population I work with has been neglected. If it's what I would've done in my mouth, it's what the patient got."

After requesting to withdraw from the plan, the dentist says the audit was called off.

"The specifics of some practices and the patients they treat have some bearing on decisions and go outside what a software package can do," says Mr. Harbold. "We can do comparisons down to a five-digit zip code so any dentist who is being audited and has specific questions should call us."

Dentists often don't understand the difference between the treatments they're providing and what's covered by contract, according to Dr. Perpich.

"That's not to say that what they're doing is wrong; sometimes it's just not covered," explains Dr. Perpich.

David Morse, former dental director of Delta Dental Plan of Minnesota and current general counsel there, says 99 percent of problem claims are for treatments that aren't covered contractually. Delta Dental of Minnesota conducts random audits of its participating providers.

"The most important thing for dentists to understand is that the vast majority of dentists don't have any problems in an audit, but that dental plans just don't cover everything," says Mr. Morse. "For example, I don't think cosmetic dentistry has ever been covered by any dental plan."

"Audits have become part of the business," says Greg Alterton, policy analyst for the California Dental Association. "But the manner in which some payers inquire information from patients implies that dentists are being investigated for possible fraud."

He's referring to the letters Aetna sometimes sends from what's called a special investigations unit to its insured members requesting them to provide information about the treatment or services they have received, as well as the cost of such treatment or services. In a letter to the California Dental Association, Diana Alviggi, investigator, responds to the CDA's concerns about such letters, which include that the notifications don't provide the patient with any explanation of the need for the requested information, but do require patients to answer questions without consulting their dentists. The CDA is urging Aetna to revise the terminology in these letters and requests that patients be informed of the routine nature and purpose of the requests for information so as not to jeopardize the integrity of the patient-provider relationship.

Mr. Harbold says UCCI only contacts patients "under extreme circumstances."

"If it gets to that point, there's a good chance legal authorities would be involved," he explains.

Dentists who aren't a part of Aetna's provider network reported undergoing retrospective claim audits. Aetna's response to the CDA is that "in order to be reimbursable under any of its plans, among other things, services must have been provided as billed and must meet the plans' definition of necessity. If the services do not meet these requirements, any payments made for the services must be reimbursed."

UCCI's Mr. Harbold reiterates the position, saying contracts don't relate to utilization reviews.

"We do audits on participating and nonparticipating dentists, whether they have a contractual relationship or not," he said. "We have a lot of administrative service types of contracts that are picking up the cost of members' care and we have to be good stewards of their money."

He says the purpose of the audit is to determine that the services they are paying for are properly reported and necessary and since they send out checks for nonparticipating dentists UCCI has the right to review what nonparticipating dentists are doing.

"There's not much we can do retrospectively, but we can require them to justify their claims prospectively," he says.

The ADA Division of Legal Affairs and the ADA Council on Dental Benefit Programs advise dentists with participating contracts with payers to become fully aware of audit provisions in those contracts and their obligations and appeal options. Nonparticipating dentists should seek advice from their personal attorneys when responding to an audit request.

The ADA Division of Legal Affairs notes that while some demands for refunds are substantial (as high as six figures), the vast majority of refund requests are for much smaller amounts.

"If the refund is large, it may well be reasonable to consult with a lawyer. However, whether or not to hire an attorney or pay back the refund is a business decision a dentist faced with a refund request from a third-party is confronted with," says Peter M. Sfikas, the ADA's chief counsel. "While dentists may have very good legal defenses, they (particularly nonparticipating providers) must consider whether or not it's financially prudent to pursue the matter in court."