A dental plan is auditing my practice - what does this mean ?

Under the California Knox-Keene Act, which regulates managed care, plan provider contracts must ensure that each 'plan shall have access at reasonable times upon demand to the books, records and papers of the provider related to the health care services provided to subscribers and enrollees, to the cost thereof, to payments received by the provider … and … to the financial condition of the provider.'

In sum, the Knox-Keene Act requires plans to assess dental practice financial records and records related to the quality of patient care. It also requires plans to include both a notice of this authority and a written agreement to this access from dentists who become contracted providers within plan networks. Hence, the contract you sign when joining the plan’s network will most likely be a good source of information about dental plan audit requirements.

Every health care service plan, including dental plans, is required to conduct periodic audits of the providers in their networks. These audits enable a dental plan to show state regulators that it is providing quality care to its enrollees and that the overall provider network is financially sound. The audits are not so much a check on the dental office as they are a check on the dental plan itself.

Dentist Problems In Billing Forms With Patients

Common questions & answers with patients insurance collections and dental benefits plans.

What can I do if a patient refuses to pay for what insurance won't cover ?
When the parents are divorced, who should pay for a child's treatment ?
Is it reasonable to check my patient's credit history before I start treatment ?
Can I charge interest for late payments ? If I do so, am I required to notify patients before I start charging interest ?
What notices am I legally required to provide patients to whom I offer third-party financing ?
What if the patient doesn't return for completion of the treatment and the dental plan has already paid for it ?
Can I offer a discount to my patients who pay in full prior to treatment ?
Are there legal problems in giving discounts to family, staff or colleagues ?
If a patient is behind on payments, can I withhold records or stop treatment ?
How do I collect an unpaid balance if the patient is in bankruptcy ?
A patient is owed a refund from overpayment, but I cannot locate the patient to send the refund. What do I do with the funds ?
What do I need to know about working with a collection agency ?
What are the federal and state laws that apply to my collection efforts ?
Is there a statute of limitations for collecting debt ?
Is small claims court an option for collecting unpaid bills ?
What should I do if a patient isn’t satisfied with the quality of treatment and wants a refund ?
Should I use the fee allowed by the plan for each procedure or my own usual, customary and reasonable (UCR) fee ?
Can I waive patient copays ?
Can I establish a discount program in my practice for patients, and what are the legal requirements ?
How soon must I submit a claim in order for it to be considered valid ?
How soon must a dental plan or insurer pay submitted claims ?
What options do I have if I disagree with the insurance plan's payment decision ?
A dental plan is auditing my practice - what does this mean ?
Does an auditor have the authority to access patient records ?
How can a dental office prepare for an announced audit ?
What if the office fails the dental audit?
Are plans required to pay for in-hospital dental treatment ?
Does obtaining a prior authorization from a patient's plan obligate the plan to pay for that treatment ?
Can lab costs be charged on a claim separately from a procedure ?
Must refund demands from dental plans always be paid ?
What should I be aware of when considering contracting with a plan to join its provider network ?
Can I balance bill a Denti-Cal beneficiary for the portion of my bill that wasn't paid by Denti-Cal ?
May I charge a Denti-Cal patient for an alternative procedure that is not a covered benefit of Denti-Cal ?
Must an associate dentist in my office be separately enrolled as a Denti-Cal provider if I am enrolled as a provider ?
What is the best way to obtain information about the treatment, provider participation and payment policies of the Denti-Cal program ?
How and when your practice verifies patient insurance coverage ?
What medical plans will pay for in dental operations ?

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