Successfully keeping dental records goes beyond preventing lawsuits and insurance headaches. It’s necessary to provide excellent patient care and operate the best practice for your patients and staff alike. Auditing is required by many regulatory agencies, and having proper audit records could prevent malpractice lawsuits and other issues. In this episode of Talking With the Toothcop, I explain 7 main reasons why you must be excellent in the way you’re keeping dental records. I also outline 3 main types of audits and explain why YOU, the dentist, must justify every decision you make regarding patient care. It’s an episode packed with need-to-know information that can’t be missed, so be sure to listen.
7 reasons why you need to evaluate how you’re keeping dental records
Keeping accurate dental records is the best way to protect your patients, your practice, and yourself. To comply with regulations, minimize risk, and continually improve on the way you practice dentistry, consider these 7 reasons why keeping great records is essential.
- To reduce and ultimately prevent improper payments
- To enhance patient care
- To speed up and optimize proper claim payments
- To minimize billing mistakes in our practice
- To reduce the chances of an external audit
- To show good faith and due diligence (protect our integrity)
- To send a message to your staff that everyone should positively contribute to the practice by reporting, correcting, and learning from mistakes
Various types of audits can be used when keeping dental records
Even though it’s easy to become complacent in mundane office-keeping tasks, maintaining proper records is essential. You can ensure the quality of your records through regular auditing processes. There are 3 main types of audits that you can implement.
- Prospective/pre-bill audits
- Retrospective audits
- Limited/problem-focused retrospective audit
The first type of audit is done on a daily basis, where your office staff examines end-of-day reports and verifies every pending claim with actual treatments administered. These audits are time-consuming but prevent administrative hassles later on. The second type of audit doesn’t look at every claim or chart, but rather a snapshot of a few different types of charts. It holds everyone accountable for consistent processes. Finally, the third type of audit involves pulling 10 records, selecting one evaluation area, and examining those records against the one specific area (i.e. HIPAA form completion). The next time you pull 10 records, select a new evaluation area. This method is faster, although not 100% complete. For the full explanation of different types of audits, don’t miss this episode.
Comparing clinical notes with your dental and billing records is a crucial step
Every dental practitioner and their staff should constantly ask themselves, “Do our clinical notes describe every aspect of the billing records?” The balance between clinical notes and billing is immensely valuable when taking preventive action against unnecessary paperwork and insurance issues. It’s important to carefully examine the claims you submit to insurance providers and look for red flags that would point towards gaps in information. This episode is full of helpful information that will make your practice and your office run much smoother – you don’t want to miss it.
The onus is on YOU, the dentist, to justify which treatments you provide to your patients
As the dentist administering care, the burden of proof for explaining treatment falls on your shoulders. YOU have to justify the need for treatment and why it was necessary. This is achieved by supporting the necessity with the following pieces of information:
- A clearly stated diagnosis
- Presenting conditions that support the diagnosis
- All risk factors
- Materials used
- How you completed the treatment
- Expected vs. actual outcome
Essentially, you have to tell the whole story, leaving no detail unexplained. If you have a great way of keeping dental records, it will guide you through this documentation process. And even if the treatment was medically necessary, if your dental records don’t reflect that, the payees will assume that it was not medically necessary. Transfer all of your knowledge and patient history onto paper, and you’ll save yourself from inconveniences in the future. For even more great insights, don’t miss this episode of Talking With the Tooth Cop.
Outline of This Episode
- [0:21] 7 reasons why you need to evaluate how you’re keeping dental records
- [8:49] Why should you audit these record-keeping processes?
- [10:57] You can use these 3 types of audits in your practice
- [19:57] Comparing clinical notes with your dental and billing records is a crucial step
- [30:52] YOU have to justify which treatments you give your patient
- [35:37] The latest info on dental record retention timelines