A Case for Auditing Your Dental Records

A Case for Auditing Your Dental Records

Physician practices and hospitals routinely audit for compliance, risk management, revenue cycle and quality of care issues.  They don’t necessarily like it, but they’ve settled into the routine of doing it to minimize their losses in the ever-increasing fight for dollars between providers and payors. Sadly, few dental practices audit patient records. A lot can be learned from auditing including identification of incomplete or inadequate documentation and/or paperwork, missed billing opportunities, issues that can result in recoupments (even criminal prosecution), and a host of other issues.


A dentist’s work is only as good as his records. It is said “your talk – talks and your walk talks, but your walk talks louder than your talk talks”. Your advertising tells people about your numerous credentials, experience and otherwise how great a person you are, but do your patient records (walk) reflect your awesomeness?


Unless you have taken off your rose colored glasses and really scrutinized your records you cannot say for sure. I concede auditing is not an income producing use of your time, but it is income protecting. What you can learn from a record audit can help increase your efficiency; demonstrate your professionalism and adherence with acceptable Standards of Care; knowledge of dentistry; and understanding and compliance with regulatory requirements, all of which will lesson the likelihood of successful malpractice claims, dental board sanctions, monetary recoupments, or worse.


As dentists you are lifelong students of your profession. In addition to learning about changes in dentistry, you must study yourself, your dental team and your clinical/ billing records to ensure that collectively you continuously meet standards and improve the quality of care you provide. As a start, I recommend periodic, ongoing record auditing as a primary Continuous Quality Improvement (CQI) strategy.


Start with an external audit by objective party not affiliated with your practice to afford you an unbiased view of your records from a compliance and risk management viewpoint. Based on the feedback you get you can implement immediate changes to impact revenue, quality of care, and liability issues. Secondly, implement internal audit processes with your staff to “keep the ball rolling”. Every staff member can be involved in auditing – it’s not rocket science. Heck, everyone has a different perspective and everyone’s input is valuable and unique or at least thought provoking.


I do not advocate non-dentists questioning the dentist’s treatment decisions – that is inappropriate. However, a non-dentist can look at a record and observe that the information in the record does not make sense as it is written, or identify crucial information is missing. Doing the audits is important. Knowing what to look for is important too, but implementing corrective action, making use of the feedback you get from an audit is crucial.


Billing records should be compared against clinical notes to verify that one substantiates and supports the other from the perspective of “if it is not written, it did not happen”. Auditing is about verifying that adequate consent for treatment was obtained, medical history was reviewed, the correct number and type of x-rays were billed (and the x-ray images match what was billed and are diagnostic quality), the narrative is complete and makes sense, and that record complies with regulatory requirements.


Auditing is a necessary evil for 21st Century dentists who wish to be successful in today (and tomorrow’s) regulatory climates. Times are changing. Among the changes is the government’s expectation that providers identify and correct their own errors/ mistakes, prevent criminal acts and maintain records to prove the same.


Dentists often resist doing audits because they feel that the practice is doing fine financially or they do not want to spend the money that an audit might cost. Sometimes, it is because of ignorance or foolish pride. This is not only dangerous, but is penny wise and pound foolish. The reality is insurance companies are looking for every reason not to pay and every reason to take back. Auditing can reveal mistakes if you are being paid for everything that you are entitled to.


Dentists who decide not to audit their practices could one day find themselves in a situation where they have no control over an insurance company, Medicaid or other involuntary audit (or the resulting consequences). The level of scrutiny is only going to increase and a practice would be wise to stay of top of their compliance efforts.


A Continuous Quality Improvement (CQI) audit program is one of the best ways to ensure the ongoing health of a dental practice. Continuous audits help confirm that your practice is in fact doing well, will help strengthen those areas that need to be strengthened and will help shine a light on those areas that need attention.


Lastly, it is not so much about the number of records you audit, but about what you do with what you learn and implementing whatever changes may be necessary to protect you, your practice and your patients going forward. Be sure to keep records of your audits; audit records are evidence that can serve you well in the face of fraud allegations. 


Be well. Do good. Be blessed. 


- Tink


Dental Compliance Specialists helps make dental offices safer for patients, dentists and their employees. We help our clients develop and maintain their compliance programs including OSHA/Infection Control, HIPAA, DEA regulations and prescribing practices, Radiation Safety, OIG/Medicaid Compliance, Record Auditing, and more by providing actionable systems, easy-to-use tools, robust training, and accountability. Most of our clients have never been in trouble and want to keep it that way. Sometimes, though, dentists call when they are in trouble. In either case, we are there to make a meaningful difference. If you need help call us at 817-755-0035.

Previous Article Next Article