Few people enjoy having someone look over their shoulders and mind their business. Now, more than ever, ‘outsiders’ will be minding your business. Insurance carriers, like Medicaid organizations, are watching dental insurance claims to identify ‘outliers’ or those who stick out as compared to their peers in the number and type of claims submitted for payment.

Payors have fraud, waste and abuse indicators that are designed to trigger mechanisms to check providers’ integrity when they are identified as an outlier. Being an outlier does not mean you have done anything wrong, per se. It does mean that you have submitted more claims for one or more types of treatment than colleagues in your geographic area and you are being watched more closely than non-outliers.

Insurance companies use a few predominant tools such as a provider alert; a desktop claims audit and an onsite chart audit. When claims auditors identify ‘outliers’ or indicators of possible fraud this can trigger a notice be sent to the provider that can sound like a vicious threat of shutdown or prosecution. What the letter effectively says is “you are submitting too many claims  (by volume or by type) as compared to other dentists in your area.  We’re not saying you are doing anything wrong, but we’re not sure you’re doing everything right – you’re on notice.”

The next thing that can occur is a desk audit. This is where an insurance carrier will require you to submit selected charts that may or may not have any correlation to one another. Take desk audits seriously and provide the information requested of you (all of it). Missing information may well be counted against you.

Audits not only look for fraud or bad dentistry, but also for mistakes in documentation and billing. You better believe ‘they’ will find mistakes (that’s what auditors do)! I recommend dentists use outside auditors to give them objective feedback about their documentation and billing practices (habits). You cannot possibly give yourself an unbiased review and it is unlikely you will gain much insight without outside perspective.

Don’t be an outlier

Mistakes are known as overpayments (monies paid that were not justified). Once an overpayment is identified you are on the hook to pay the money back. This can be duplicate billing, improper coding, treatment by non-credentialed (or unlicensed) provider, treatment by excluded provider, lack of supporting clinical documentation, lack of consent (failure to meet the standard of care), no vital signs when required, missing (or poor quality) radiographs or a number of other issues.

Overpayments can be caused either by accident or by design. However, the cause is not the compelling issue THAT an overpayment occurred is. Insurance companies and the government expects healthcare practitioners to identify and correct their mistakes; if the payer or the government has to identify and cause corrective action IT WILL HURT. This has been proven time and again.

By insurance program requirements and even a number of state and federal laws providers are required to ensure they receive only justified payments. The only way to verify only proper payments are received is for providers to have effective internal auditing processes in place. This is difficult to do for small providers with limited resources, but some audit systems must be implemented and providers must have documentation of those efforts. There are several audit types and processes, which I will outline in future articles.

Please understand this is not an issue faced only by Medicaid providers. Insurance carriers are involved in these processes and accountability and for the same reasons – money. You are good people, good dentists and good business owners, right? You have to prove it!

Remember, if it was not written, it did not happen, it was not discussed and you cannot prove it. It is not enough that you audit, but you need to show your work.


A former Law Enforcement Officer/ Dental Board Investigator, Mr. Duane Tinker is the CEO of Dental Compliance Specialists. Mr. Tinker and his compliance specialists provide compliance consulting, auditing and training services for dentists and Dental Service Organizations nationwide on compliance risks including OSHA, HIPAA, Dental Board rules/ regulations, state radiology rules, DEA and state drug regulations, and Medicaid. He often speaks for dental societies and study clubs. Mr. Tinker can be reached at (817) 755-0035 or click here to email.

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