What if the office fails the dental audit?

The likelihood of a dental office actually failing a quality assessment audit is fairly low — probably nonexistent. Again, the purpose of the audit isn't so much to evaluate the office as to enable the dental plan to assure the state Department of Managed Health Care that it has a high-quality network of providers. The subject of the audit is really the plan, not the provider, and in this sense, it is in the interest of the plan that its offices pass.

Nevertheless, a given office may show a need for improvement in one or several audit categories. The plan should always provide the office with the results of the audit. If the discovered deficiencies are minor, the plan may simply instruct the dental office to check off each item when the deficiency is corrected and return the checklist to the plan. If a deficiency is more significant, the plan may ask for specific documentation that it has been corrected. If a large number of deficiencies are discovered during an audit, the office may be put on a list to be re-audited the following year, to ensure that the corrections have been made. Other than this, there will likely be no penalty for failing to meet audit categories. However, a dental office that has been audited a number of times and has shown reluctance or inability to correct deficiencies may be dropped from the dental plan's provider network. There is no legal or regulatory penalty for offices that fail to achieve a 100 percent score in an audit.

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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