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Law Educator, Esq.
Law Educator, Esq., Attorney
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PAULMJD: Stressed with State dental Medicaid Audit. I

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PAULMJD: Stressed with State dental Medicaid Audit. I am a general dentist participating with smile for children program. It's something I feel passionate about to give back to the community one day a week , I crossed off my schedule to see the underserved children at my office. I knew my time will come with the audit. As much as my documentation is, it's still not enough to protect myself incase of an audit.

I just received the letter today asking for 20 charts. They call the audit: Quality Improvement and Utilization REview and they said " the purpose of the audit to to monitor and correct over utilization that occurs as a result of improper billing practices.... One goal of this audit is to provide an adjunctive service to provider profiling in order to identify all potential instances of upcoding, unbundling and any other inaccurate reporting of services performed....The other goal is to verify that the charting and patient treament requirements for participating providers are being incorporated into everyday practices. The letter was fairly nice. They only asked for TREATMENT NOTES, TREATMENT PLANS, MEDICAL CONSENT, MEDICAL HISTORY, RADIOGRAPHS FOR THE 12 MONTHS SPECIFIED. They did not ask for account ledger, lab fee, or clinical chartings or examination charting.

The charts requested are only 11/30/11-11/30/12. Of the 20 charts: 20% of young children (less than 6 years old in 4 patients)with all work (mostly fillings and cleaning in one visit) done under IV sedation (by an anesthesiologist for the sedation at my office). 40 % are teens having minor fillings and cleanings. 20 % just have xrays and cleanings and no procedures during the 12 months requested. 20% just xrays and consultations no other work. Because the charts vary in pattern, I could not see any patterns. I think they want to see the 4 patients that had intravenous(iv) sedation because alot of procedures were done in one visit. The rest of the charts that they request for that 12 months did not have much work done...some fillings and xrays and cleanings....

My questions are ...should I be worried? WEll...they don't send me the audit letter for no reasons! Should I consult a healthcare lawyer just to help protect my reputation and license? I know I should not even call the "utilization review specialist". They are called not "special investigator unit", so I am not sure if they are the same kind of investigator.

Please help...I am nervous because I know as much documentation that I am doing, I still can't protect myself from minor flaws. Healthcare is becoming less satisfying to practice with the new regulations. Should I get out of providing services to the children with medicaid? I told myself if I get through this audit with a passing score, then I will continue to provide services for the smile for children program with doing less procedures in the future and refer out most procedures.

What is a good business with out this kind of stress! I can work hard but I can't control this mental stress. And I know there will be future private insurance audits! Any advice is appreciated. Thank you.
Submitted: 1 year ago.
Category: Business Law
Expert:  Law Educator, Esq. replied 1 year ago.
Actually, regardless of your innocence in here you should not go into these audits without an attorney. The problem with medical practice today is the regulations require almost a PhD in billing to keep up with and to make sure all of the records are done properly. The issue is that no doctor can get it all straight and survive an audit without any violations and the key is that there is no intentional billing fraud or gross errors in the billing. The attorney will sit down and keep the audit focused on the fact that there is no intentional misconduct or billing practice fraud. I am afraid there is no way any doctor can protect themselves from all of these error.

You need to engage a healthcare attorney to represent you in the audit. You also need to consider at least a part time billing/office manager who is certified and qualified in billing and charting practices to keep your records straight. This is all you can do to keep yourself protected.

The botXXXXX XXXXXne is most doctors go through these audits with nothing more than a warning when minor violations are found and it is not until major violations or intentional fraud are found or repeated misconduct that they pursue significant fines or sanctions against the doctors.


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Law Educator, Esq., Attorney
Category: Business Law
Satisfied Customers: 89517
Experience: All corporate law, including non-profits and charitable fraternal organizations.
Law Educator, Esq. and 7 other Business Law Specialists are ready to help you
Customer: replied 1 year ago.

The intent of the audit is to find flaws and request a refund check, right? And they would get a % of the 20 charts and bring the % back to 6 years when I started the Smile-for-Children Program. If they do extend back, can I have an appeal to fight that? What is the chance of winning? Do they threaten you because they think we will not fight with being a small business owner?

Expert:  Law Educator, Esq. replied 1 year ago.
The intent of the audit is verify your billing practices, so they claim. They would have to check all of the patient files to fine you any appreciable amount, the small number of files they are requesting are just to determine whether or not it is warranted to go further to examine more files. Yes, you can have an appeal to fight all of this. I cannot tell you the chances of anything because we do not even know whether or not there are any violations at all or what those violations may be in order to determine your chances.

They do not threaten you because they are a small business owner. This is something they do to many doctors who offer free or low cost care just to make sure everything is being done properly.
Customer: replied 1 year ago.

They are just requesting for files. I should look through each file and act as an auditor to see if I am complete? At this point of the audit, should I contact a healthcare attorney or should I submit the files?

Expert:  Law Educator, Esq. replied 1 year ago.
You should look through the files first, then if you find nothing wrong with them submit them. If you find any mistakes, you should contact a healthcare attorney to represent you in the audit.
Law Educator, Esq., Attorney
Category: Business Law
Satisfied Customers: 89517
Experience: All corporate law, including non-profits and charitable fraternal organizations.
Law Educator, Esq. and 7 other Business Law Specialists are ready to help you

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