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Audit ready?

24 September 2018

Surgery without audit is like playing cricket without keeping the score1 and as more parties move to audit dental surgeons and other dental practitioners over the next 12 months, Dr Annalene Weston, dentolegal adviser at Dental Protection, asks you to consider: what will they find if they audit you?

The Chronic Disease Dental Scheme audits of 2009-2012 sent shockwaves through our profession as, although in most cases treatment had been provided and evidenced, monies were clawed back solely due to administrative failings. There is no doubt that as a cohort, we approached this third party financial arrangement with Medicare with the incorrect but not unreasonable assumption that work = money. It didn’t.

The media launched into a feeding frenzy with headlines encompassing the ‘rorting’ by the ‘dodgy dentists’, but we collectively lobbied and pushed back and worked smarter. As our naivety fell away, so did the clawbacks, and we all sat back and patted ourselves on the back for a job well done. A series of Health Fund audits closely followed, and led to automatic de-recognition of provider status for some, and again we, as a cohort, successfully pushed back and lived to use HICAPS another day.

But what have we learnt? Perhaps more alarmingly, it is not what we have learnt, but rather, what the third parties have (third parties include all private health insurers as well as Medicare). They have learnt that auditing dental practitioners will likely uncover failings in their administration and record keeping, and that these failings can enable these third parties to reclaim monies from those with provider numbers, regardless of whether the treatment was provided to the patient.

As 2018 draws to a close, and 2019 begins, several agencies are auditing dental practitioners and auditing hard, so let’s explore those in turn.

Infection control audits

Another significant infection control breach in NSW has sparked a further round of infection control audits. Initially paper-based, this audit can lead to a practice inspection and it is therefore prudent to be prepared for both. The Dental Board has a helpful page that sets out the infection control obligations of all dental practitioners, and includes a self-audit tool, which you can use to identify and remedy any possible shortcomings. 

Financial audits

Those who have a provider number are responsible for the potential replay of every code billed under that number, regardless of who billed it. Both Medicare and the Health Funds are currently auditing, to seek out the outliers on the assumptions that they are probably incorrectly billing to have a pattern that differs significantly from their peers. 

They are seeking ‘upcoding’ – charging a 114 instead of a 111 or a 532 instead of a 531 – and when queried, the only way you can verify the appropriateness of your charging is through your dental records. Sadly, this is severely letting many of us down, and if you cannot prove that a code has been utiltised appropriately, then the third party who contributed to the fee can claim that money back; with Medicare now being empowered further to not just ask for the money, but garnishee the funds in certain circumstances (enforce the repayment through a court order that enables them to collect the funds directly from your bank account). 

The best protection you can give yourself is accurate record keeping, and Dental Protection has several resources which can assist you with this: workshops, webinars and a range of publications and resources.

AHPRA audits

As many will be aware, AHPRA routinely audit registrants to ensure compliance with certain standards, such as the requirement to hold appropriate professional indemnity insurance, and also whether a practitioner is meeting the continuing professional development requirements. It would seem that this is to be extended into an audit of dental practitioner advertising, commencing next year.

In preparation for this, we would recommend that dental practitioners review their advertising, and the Dental Board has provided some helpful resources to enable this.

Operation Carina

A recent communique from the ADIA has highlighted that the Therapeutics Good Administration (TGA) will commence auditing in January 2019 to assess the illegal importation of dental products. More information is not available at the time of writing, but this video may clarify the role of the TGA; registered dental practitioners need to be mindful that the TGA are legislatively empowered to prosecute those illegally supplying dental products.

In summary, while we may feel that auditing is most decidedly ‘not cricket’, it is upon us, and the best way to prepare and protect ourselves is through a pre-emptive self-audit and self-correction before any shortcomings are bought to the attention of those who may take umbrage.

1 Hugh Brendon Devlin, Founding Director of the Surgical Epidemiology and Audit Unit, Royal College of Surgeons of England

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