Health fund audits

What’s happening? ADA SA recently received notification from a major Health Fund (PHI) indicating a new round of compliance auditing is about to commence.

How are dentists related to third party payment providers? ADA Policy statement 5.5 describes FUNDING AGENCIES as being third parties which make contributions to the payment of the fees charged by dentists, including:

  • statutory authorities, e.g., Commonwealth and state health departments,  transport accident authorities, workers’ compensation authorities;
  • Private Health Insurers (PHI’s) through –

  1. Rebate entitlements (most health funds); and
  2. Contracted dentist schemes (also known as preferred provider schemes) which involve a dentist agreeing to work for a fixed fee for service for a contracted period, or capitation schemes.

Do payment providers monitor dental claims? All PHI’s monitor dentists’ servicing and claims patterns. Audits are commonly performed of dentists whose claims profiles fall outside expected industry ‘norms’.   Sometimes, audits are prompted by complaints or tip offs from members of the public.  

Why are audits performed? The focus of most health fund auditing is to ensure the integrity of benefits paid by the health fund to their members.  A health fund audit may ask you to verify the validity of services claimed by your patients.

Who is responsible? It is important to note that the responsibility for providing appropriate clinical care rests with the individual treating practitioner.  However, dentistry is unique in that allied practitioner claims can be submitted under a dentist or dental specialists provider number.   In the event of a health fund audit and/or restitution payment demand, it is the owner of the provider number who is held responsible.

How do I protect myself? The message is clear: keep good records to show:

  • the claimed service was provided;
  • the claimed service was clinically relevant or necessary;
  • the tooth that was treated is recorded (tooth ID)
  • the item code used for claiming matches the service which was provided to the patient; and
  • the patient/parent consented to the treatment and costs associated.

Is there a particular focus of current audits? Yes. The current auditing relates to billing compliance in accordance with ADA descriptors.  If you have any questions or concerns, please contact the Branch on 8272 8111.