Dental Audit

Healthcare Horizons performs comprehensive dental claims audits for clients who provide self-insured dental benefits for their employees. For the best and most accurate results, we audit 100% of dental claims; doing so not only helps us identify specific instances of overpayment, but also enables us to detect systemic errors that can be corrected for long-term savings for the client. Upon request, or if contractual obligations require, we can also perform the audit by testing a random sampling of claims.

Our dental insurance claims audit process is straightforward

  1. Gather the data. We request general plan information from the client as well as claims and eligibility data from the third-party administrator (TPA).
  2. Analyze the data. We test for a wide range of errors based on a number of criteria (described below). This testing culminates with an on-site visit to the TPA.
  3. Determine root cause. We work with the TPA to identify the root cause for errors and make recommendations for process improvement.
  4. Reporting. We deliver a full report of claims in error as well as a written report of findings.

The following is a partial list of categories examined by Healthcare Horizons.

  • Eligibility
  • Dental coding accuracy
  • Duplicates
  • Excluded services
  • Coordination of benefits
  • Annual and lifetime benefit maximums
  • Patient responsibility (deductibles, coinsurance, copays)
  • Pricing

When the audit is complete, we deliver a comprehensive report that details the findings of the audit, the areas we tested, and a list of erroneous claims. When applicable, we also identify root-cause issues and make recommendations for correcting these issues to reduce the risk of future overpayments.

At Healthcare Horizons, we go the extra mile to make sure we are providing the most thorough and accurate auditing information to our clients, resulting in higher recovery rates and greater long-term savings. To learn more about our dental audit services, contact us here.