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Dentists facing compliance audits have ADA resources in their reach

April 16, 2018

By Michelle Manchir

Editor's note: This is the 11th story in the Decoding Dental Benefits series featuring answers and solutions for dentists when it comes to the world of dental benefits and plans. The series is intended to help untangle many of the issues that can potentially befuddle dentists and their teams so that they can focus on patient care.

Dr. Cynthia Olenwine remembers the afternoon in 2008 she opened a letter from an insurer informing her she was flagged for a compliance audit.

"I was angry and I felt threatened," said Dr. Olenwine, a Pennsylvania dentist and a member of ADA Council on Dental Benefit Programs and Code Maintenance Committee.

Certainly, the thought of an audit can cause dread to many practicing dentists who may question why they were chosen for one or fear the cumbersome paperwork that audits can require.

DDB LogoCompliance audits can result in having to reimburse payments to insurers, and in serious cases where fraud is uncovered, cases can be transferred from third party payers to state and federal authorities.

After receiving her audit notice letter, Dr. Olenwine, now retired from her practice, said she was informed she was flagged because she provided significantly more two-surface composites than other dentists in her area.

 "I took a deep breath and thought 'you know what, I have nothing to hide. I have nothing I'm afraid of. I'll just cooperate.'"
Because she uses a digital system, pulling up records of the 50 patients the insurer asked for was bearable. She had photographic evidence that the work was necessary and completed, and less than a month later, the review was over.

"My experience with audit was positive because I went into it knowing I was not going to be confrontational, knowing I was bound by contract and realizing auditors were just doing their jobs," she said.

In many cases, when dental professionals sign a contract with an insurer, they agree to be audited at will, said Dr. Linda Vidone, vice president of clinical management and senior dental director at Delta Dental of Massachusetts.

"Insurance carriers conduct audits to ensure contractual obligations are being adhered to and the regulations set by the state and/or federal government are being upheld by the providers," said Dr. Vidone. "The purpose of these audits is to verify that the treatment was necessary, performed, performed properly and billed correctly."

In some cases, dentists are flagged for audits when their billing patterns appear "outside the norm" of treatment and billing sequences when compared to their peers, Dr. Vidone said.

"Carriers have vast databases on virtually every dentist and therefore can analyze and compare dentist treatment patterns and billing sequences," she said. "They determine the norm and then focus on those providers that appear outside the norm. The compliance audit can help to decide why a doctor's treatment mix is different from other doctors in the carrier's network and why that doctor's billing patterns are so different from other providers. There may be perfectly good/valid reasons why one provider for example performs a higher number of crowns or build ups than other providers in the carrier's network."

In Dr. Olenwine's case, she was the largest service provider in her area in Pennsylvania, thus accounting for the above-normal amount of two-surface composites for which she was billing.

Dr. Olenwine could see why this happened, since she made the switch from fee-for-service to accepting insurance following the 2009 economic downturn. At the time, many of her long-time and established patients were no longer able or willing to make payments without using insurance, she said.

For dentists concerned they could come under review, both Drs. Vidone and Olenwine suggest to always be prepared for one by simply keeping comprehensive and up-to-date records and being familiar with CDT codes.

"Dentists selected for an audit have only their records to protect them; effective chart notes and radiographic images are essential," said Dr. Vidone. "If it's not documented in the patient's dental record, you didn't see it, you didn't say it, you didn't do it, it didn't need to be done, and therefore, it didn't exist. Always make a chart note regardless if you are billing for the procedure or not and review ADA documents on recordkeeping to determine what should be included in your patient records."

The ADA document is available online at

Dr. Olenwine said her subscription to a third-party insurance vendor was also valuable when she underwent the audit. She also said her maintenance of a digital record-keeping system was essential, as it made it manageable for her to find and send the records.

For Dr. Olenwine, the potential to be audited by insurers comes with the territory of accepting insurance.

"You're getting patients from them who can find you online and want your service," she said. "There's no free lunch."

Furthermore, she said, it doesn't much matter if practice staff is responsible for billing errors. When it comes to audits, it's the dentist who will be affected by the consequences.

"You're the CEO of your company," Dr. Olenwine said. "The buck stops with you."

Still, there may be cases in which requests for audits can and should be mitigated.

The ADA Policy on audits of private dental offices by third-party payers (Trans.1990:540; 2005:325) states that in instances where a dentist has expressly agreed in a contract to comply with office audit procedures, the dentist is encouraged to obtain a written description and scope of the audit procedure and seek the advice of his or her legal counsel, in order to be informed of his or her rights and potential liabilities regarding the audit.

Furthermore, when a dentist is under no direct contractual obligation with a third-party payer, the decision to comply with requests for in-office audits should be made independently by the individual dentist after consulting with his or her attorney for a determination of the legal implications of such decision.

The policy also states that dentists should consider their potential legal liability under applicable state and federal privacy laws in consultation with their attorneys when negotiating contracts that oblige them to allow third-party payer audits of the practices.

Drs. Vidone and Olenwine, along with Nick Messuri, vice president and general counsel for fraud prevention and recovery at Delta Dental of Massachusetts; and Dr. Christopher Bulnes, a Florida dentist and vice-chair of the ADA Council on Dental Benefit Programs, participated in a March webinar on the topic of compliance audits and utilization management.

Staff from the ADA Center for Dental Benefits, Coding and Quality can help dentists with dental benefits-related and coding problems, questions and concerns. Call 1-800-621-8099 or email

The ADA has created a landing page for dental benefits information that can help dentists address and resolve even their most vexing questions,, part of the Center for Professional Success.

Previous installments in the Decoding Dental Benefits series are available at