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What Dentists Need to Know About Medicaid Fraud & DentQuest Audits

December 10, 2023

What Dentists Need to Know About Medicaid Fraud & DentaQuest Audits

Medicaid fraud is a big issue facing dentists today. With increased scrutiny from auditors like DentaQuest, it’s important for dentists to understand the rules and potential penalties surrounding Medicaid billing. This article provides an overview of key things dentists should know.

Medicaid Billing Rules

Medicaid has strict requirements regarding billing and documentation. Common problem areas include:

  • Upcoding – Billing for more expensive procedures than were actually performed
  • Unbundling – Billing each step of a procedure separately instead of using an all-inclusive code
  • Lack of documentation – Not having enough records to support billed services
  • Medically unnecessary services – Performing procedures primarily for financial gain versus patient need

Even innocent mistakes can lead to allegations of fraud if billing patterns seem questionable. It’s essential for dentists to understand proper coding and documentation guidelines to avoid issues.

Audits Are Increasing

Government dental programs like Medicaid are increasing audits through contractors like DentaQuest. These audits scrutinize billing records, patient charts, and other documentation looking for problems.Any billing irregularities or documentation shortcomings may result in demands for repayment and potential fraud allegations. The stakes are high in these audits, so dentists need to take them seriously.

Intent Isn’t Required for Fraud Charges

Here is a key point dentists often overlook – intent isn’t required for fraud charges. Even if you made an innocent mistake, failing to follow coding or documentation rules can still lead to civil or criminal liability.And once fraud charges happen, the professional and financial consequences can be severe. This makes a compliance-focused approach critical for dental practices.

Conduct Internal Audits Proactively

To get ahead of potential audit issues, dentists should conduct regular internal claims reviews. Examining documentation and billing patterns can identify problems areas to address proactively.Outside consultants can also provide an independent audit. But legal counsel should be engaged if using an external auditor to preserve confidentiality.Being proactive helps dentists address innocent issues before they become fraud allegations. It also shows regulators you take compliance seriously if questions ever arise.

Have Documentation Processes in Place

At the heart of most Medicaid audits is documentation. Dentists must have detailed patient records supporting medical necessity and specific billed procedures.This means having processes in place regarding:

  • Treatment planning – Documenting why procedures are needed and how they benefit the patient. Get second opinions for extensive treatment plans when possible.
  • Informed consent – Having patients sign forms acknowledging proposed treatments, risks and alternatives. Fully inform patients to avoid complaints that services weren’t necessary.
  • Recordkeeping – Thoroughly documenting each appointment with detailed narratives, x-rays, photos and models. Records should clearly link treatments to billing codes.

Following documentation best practices is key to defending your standard of care if audited.

Seek Legal Counsel if Issues Arise

If auditors allege problems with billing or documentation, contacting qualified legal counsel is essential. Experienced attorneys can guide you in responding appropriately to audit inquiries.Counsel can also negotiate settlements or payment plans if repayment demands seem unreasonable. And if fraud charges emerge, skilled lawyers are critical to defending your case.Having the right legal help can make all the difference in resolving audit issues favorably. So consult experienced counsel at the first sign of problems.


Increased government dental audits make compliance more important than ever for dentists. Avoiding issues requires understanding billing rules, conducting internal claims reviews, having documentation protocols in place and seeking legal counsel promptly if problems occur.Staying informed on evolving Medicaid requirements is also key. Joining industry associations, reading updated regulations and participating in continuing education helps dentists stay compliant.With the right knowledge and preparation, dentists can effectively manage Medicaid obligations and audit risks. But overlooking compliance protocols can have severe professional ramifications. By making informed choices today, dentists can protect themselves as well as provide ethical care to underserved patients relying on government programs.


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