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Medicaid and Medicare Audits: What to Expect

The Medicaid and Medicare programs are auditing dental practices more often than ever before. Because these audits are increasingly common, dental practice owners should be aware of general guidelines for ensuring that the audit will go as smoothly as possible with the least amount of interruptions to the dental practice.

It is extremely important to keep all documentation organized. Dental practice owners must train their staff on the importance of keeping proper documentation in every patient file and timely filing it away. Practice owners should also become familiar with the Medicaid and Medicare manuals and regulations. Following these simple steps will save dentists a lot of time and money if Medicaid or Medicare ever decides to audit your practice.

Medicaid and Medicare generally audit dental practices that have been flagged because of a certain item claimed or because of the volume of claims that these programs have paid to your practice. For example, a dental practice may be audited because of multiple claims for the same date of service, or because a claim was submitted for a procedure outside of a dentist’s specialty area. In addition, if the dollar amount of claims from your dental office is greater than average for dental offices in your area, Medicaid or Medicare may audit your practice.

If a Medicaid or Medicare audit letter arrives in the mail alerting you that your dental office will be audited, it is crucial that you promptly follow all instructions contained in the letter. All correspondence from Medicaid or Medicare should be taken seriously. You will be asked to make certain patient records available for audit. For audit requests in the mail, you should make every attempt to meet the requested deadlines for the submission of records. If you are unable to produce the records within the time period allotted, contact the auditor and request an extension.

When submitting documents to the Medicaid or Medicare auditors, always submit copies of your records (or keep copies for your files if the original documents are requested). If you send your original documents and do not make copies, you may never get the records back.

For audit inspections conducted in person, the auditors will request that you make certain records available for inspection. Upon the auditors’ arrival at your dental practice, the records may be scanned and reviewed onsite or may be taken from your office to be reviewed at an offsite location. Typically, the auditors will conduct an entrance interview to explain the auditing process and which records they will be reviewing. If the audit is being conducted in your dental practice, it is possible that the audit will last several weeks and it is a good idea to find the auditors a space to work in your dental office that will not interfere with your daily business.

If the audit is conducted onsite, it is very important that you and your staff avoid engaging in unnecessary conversations with the auditors. You should always answer all questions directly and truthfully, but participating in lengthy discussions may have an adverse effect on your audit, as what you discuss may be used against you in the final report. Remember that although the auditors may be friendly, they are in your dental practice because they believe there may be a problem and their job is to uncover a violation of your agreements with Medicaid or Medicare.

Once the audit is complete, an exit conference may be held so that the auditors may explain the results of their audit. This is a good chance to clarify any questions that you have and to obtain an indication of what may be in the final report.

After the Medicaid or Medicare audit is complete, you will receive a letter and written report that details the results of the audit. This letter may arrive several months after the auditors leave your office. Any alleged errors that the auditors found will be identified in the report. If the auditors found claims for services that they did not believe were properly documented or billed, the report will include the amount of improper claims billed to Medicaid or Medicare. Your rights to appeal will also be explained in the letter.

If the letter provides a timeframe within which to respond for reconsideration, it would be prudent to respond with an explanation for the claims that the auditors found. If the request for reconsideration is not successful, you may appeal the findings.

It is very important that dental practice owners address the problems found in the auditor’s report so that the Medicaid and Medicare programs are aware that their findings are taken seriously and the same issues will not arise if your dental practice is audited again. If billing or documentation issues were identified, procedures must be changed so that these issued are addressed and resolved immediately.

If Medicaid or Medicare finds that improper claims were billed by your dental practice, there may be one or more actions taken against you. Medicaid may suspend payments to your dental practice or suspend your participation in the Medicaid or Medicare programs completely. In addition, your dental practice may be referred to the Attorney General Medicaid Fraud Control Unit.

It is crucial that dentists familiarize themselves with the Medicaid and Medicare manuals. For example, you can learn more about Medicaid and Medi-Cal (the Medicaid program in California) by heading to the IEHP website. Ultimately, dental practice owners that adequately train their staff on Medicaid and Medicare procedures and regulations and keep all documentation organized will save a lot of time and money if their dental practice is audited.


Stuart J. Oberman, Esq.
President & CEO | Website | + posts

Stuart J. Oberman is the founder and President of Oberman Law Firm. Mr. Oberman graduated from Urbana University and received his law degree from John Marshall Law School. Mr. Oberman has been practicing law for over 30 years, and before going into private practice, Mr. Oberman was in-house counsel for a Fortune 500 Company.

Stuart J. Oberman is the founder and President of Oberman Law Firm. Mr. Oberman graduated from Urbana University and received his law degree from John Marshall Law School. Mr. Oberman has been practicing law for over 30 years, and before going into private practice, Mr. Oberman was in-house counsel for a Fortune 500 Company. <strong><a href="https://obermanlaw.com/people/stuart-j-oberman/"><span style="color: #0059b8;">Read More =></span></a></strong>