Episode 4: PREVENTATIVE MEASURES: HOW TO ACE DENTAL AUDITS

Summary: In this episode, Paul Logan interviews Dilaine Gloege, an expert with 38 years of experience in dentistry and founder of Tidewater Dental Consulting. Dilaine discusses the importance of accurate documentation and coding practices for dental teams. She emphasizes the changing standards in dental documentation to align with healthcare provider expectations, the reasons behind audits, and best practices to avoid them. Dilaine also provides practical advice on how to handle audit notifications, the significance of internal audits, and the role of each team member in maintaining proper documentation. For dentists looking for further resources, Dilaine recommends annual updates to coding manuals and continuous team training.

Host: Paul Logan of the Virginia Dental Association. Paul focuses on member advocacy, developing resources for dental students and early career dentists, and working with a broad array of stakeholders to elevate and address Virginia’s dental workforce needs. Paul currently serves on the executive committee of the Coalition for Modernizing Dental Licensure and the College Board of J. Sargeant Reynolds Community College. Outside of work, he’s trying to keep up with his three- and six-year-old daughters.

Guest: Dilaine Gloege is a dental coding expert who is committing the second wave of her career to writing, teaching, and consulting clients. As a former insurance coordinator and practice administrator, she brings over 38 years of practical experience to bear on her work. Dilaine has authored coding and insurance publications and is a highly sought-after speaker and educator. Whether she is leading an educational program, providing consulting services, or speaking about her craft, her commitment to creating expertise in the field is evident.
 
Dilaine is featured as a co-author of “Ace Your Audit” in the Virginia Dental Journal (Volume 102, Number 2).

Reach out to Dilaine via email at delaine.gloege@gmail.com or visit her website at https://tidewaterdentalconsulting.com/

Credits: 

Host/Producer: Paul Logan

Guest: Dilaine Gloege

Post-Production/Editor: Shannon Jacobs

Subscribe, share, and send your feedback and topic ideas to thefulcrumpodcast@vadental.org.

The information, opinions, and recommendations presented in this Podcast are for general information only, and any reliance on the information provided in this Podcast is done at your own risk. This Podcast should not be considered professional, medical, or legal advice.

Music in this episode from Epidemic Sound

Transcript

[00:00:05] Paul Logan: Today on the Fulcrum Podcast, we're joined by Dilaine Gloege, founder of Tidewater Dental Consulting Dilaine's article, "Ace Your Audit" appears in the April issue of the Virginia Dental Journal, and today she's going to share her expertise on how every dental team member can play a role in ensuring that your documentation tells the full and accurate story to avoid triggering audits and acing them when they do happen.  

[00:00:28] Paul Logan: Thank you Dilaine for joining us today. Dilaine, could you just tell us a little bit about yourself and what you do? 

[00:00:36] Dilaine Gloege: Thank you so much Paul. And thank you for inviting me to share a little bit about my passion, , as far as educating dental teams. My name is Dilaine Gloege, and I have been in dentistry 38 years.

[00:00:48] Dilaine Gloege: Absolutely just as passionate today about dentistry as I was when I first started. My background is a clinical dental assistant and a very progressive GP practice. I had the honor of working alongside Dr. Charles Blair at Practice Booster and Insurance Solutions Newsletter.

[00:01:06] Dilaine Gloege: And during my seven year period there, I was, helping Dr. Blair develop a lot of resources for dental teams for coding and proper billing practices and assisted thousands of dental teams. And I launched my own company a few years ago and I, I continue my goal of educating dental teams to ensure proper coding and documentation practices across the country.

[00:01:31] Dilaine Gloege: So that's what I love and thanks again for having me today. 

[00:01:36] Paul Logan: Thank you. And just to set the stage for the stakes of this conversation, 38 years of experience, can you tell why is it important for dentists to be focused on this issue? 

[00:01:46] Dilaine Gloege: So in dentistry, historically, we've not documented as thoroughly as our other healthcare professionals in the medical world.

[00:01:57] Dilaine Gloege: And now we're considered a crucial member of the patient's healthcare team and we're healthcare providers. So our documentation standards have changed a lot. Coding has changed. The insurance has changed. We have more medical plans with dental benefits embedded in those plans.

[00:02:20] Dilaine Gloege: And so we're healthcare providers. So our documentation and our coding practices need to look like we're healthcare providers. And I've seen a lot of changes in dentistry. I remember when I was documenting a crown 38 years ago on behalf of my doctor, I might would say tooth number 14, crown prep. Two carpules of lidocaine. And if I was having a great day, I remembered to enter the shade. We never had to document to specificity and tell why we did a procedure. Why was it necessary? That's changed. 

[00:02:59] Paul Logan: So tell me what, what can prompt an audit? Like No practice wants to see, , that notice uh, is it, is it always something that's in an office's control?

[00:03:09] Dilaine Gloege: No, not always. There are various reasons why a practice can be audited. And it's no longer a matter of if you're audited, but when you're gonna be audited. A patient can file a grievance. And they can file that grievance with your state dental board, file a complaint over a billing issue or how you handle their insurance claims.  

[00:03:32] Dilaine Gloege: They can file a grievance with State Attorney General. They can file a grievance with your insurance payer. So a patient complaint or a grievance can prompt an audit. Then we have random audits that insurance payers do, and it's not about the reimbursement. That's what I like to make very clear.

[00:03:53] Dilaine Gloege: It's about ensuring quality patient care, and that is our ultimate goal. And we do that with our documentation and proper practices. An insurance payer can do a random audit and sometimes they're not so random. Sometimes we get deemed to be an outlier, so we can compare one provider in a zip code area or a geographical area and compare the number of procedures that they do of a certain type of procedure, like scaling and route planning compared to their peers in the same area. And if we do a higher percentage, then it may prompt an audit that's called a utilization review. If you're doing a higher percentage of a certain procedure than your peers, then you can have a focused review and that's focused on one particular procedure. And it might last six months . They'd review your documentation. The payer does, and it is again, it's about ensuring quality patient care. Does your documentation fully support the procedures you're rendering? And it doesn't matter if you're in or out of network with an insurance payer, you can still be audited, and if the patient does not have insurance and the patient files a grievance, your records could be audited. You know again? Did you document thoroughly? 

[00:05:20] Paul Logan: So as in, in working with your dental clients, are there any causes for audits that you find that they're consistently surprised by? Obviously a random audit is a surprise right to everyone. But as far as learning why they were audited that they find surprising, they were not expecting. 

[00:05:41] Dilaine Gloege: So during an audit, the most common surprise is realizing that their documentation is not where it needs to be. And that's where we do a lot of training with the team to ensure accuracy in our documentation.

[00:05:57] Dilaine Gloege: We have to remember, as healthcare providers, we are populating the patient's electronic health record just like our MDs. And so that's the biggest surprise what they thought they were documenting to specificity and thoroughly enough they learned that no, maybe we're not, and how can we improve on that?

[00:06:19] Dilaine Gloege: So during an audit that is a big surprise. And then we build upon that. We take what we learn and we learn together as a team how to improve our documentation and set the processes and policies in place to prevent it in the future.   

[00:06:36] Paul Logan: You said earlier that the practices should be prepared for, this is a when, not if you're going to be audited for those who haven't yet gone through this process, each case may be distinct, but can you talk about what the typical first steps are if they're being audited, and what you advise your clients to do when they learn that there's going to be a review?

[00:06:58] Dilaine Gloege: Don't ignore an audit letter. Um, you know, You have a very limited amount of time to respond. And I also encourage the practice not to try to go through an audit alone. Reach out for assistance. Reach out to an expert, an attorney, a dental focused attorney to help guide you through the audit.  

[00:07:18] Dilaine Gloege: Because if you try to go through it yourself, sometimes you don't realize the significance of it, and you need to have some guidance. That's my biggest advice. If you get that audit letter, reach out for help. 

[00:07:32] Paul Logan: Yes that's good advice. You're not in it alone. Obviously the best outcome for both, both the dentist and carriers is that there's no cause for an audit to begin with but how can dentist best provide complete documentation to tell this story to those who are reviewing their claims?

[00:07:52] Dilaine Gloege: So we're storytellers. That's what our documentation does. Our clinical note tells the story of each patient, encounter. The clinical note is everything about that encounter. It's who was treated, who provided the treatment, what treatment was rendered, how that treatment was rendered, and why was it medically necessary, even if it's for a cosmetic service. That's the why. That's why that service was provided, or it might be a restoration that was due to decay extending into the dentin. That's the why. That's the medical necessity. And if you wanna be prepared for an audit, implement internal audits. Train your team. Invest in annual training. Training for proper coding and documentation.  

[00:08:46] Dilaine Gloege: Because we've never had formal training in these areas. Now we're being held accountable and it's important that we implement annual training for the entire team and we implement internal audits. Randomly pull charts together as a team. Have someone who was not associated with that patient visit or encounter read that chart note. If that person has questions about what was done, who was treated, who provided the care, how it was done, and why it was necessary. Then as a team, you need to go back and look at that chart note, what can we do to improve upon that? Having those processes in place is gonna go a long way if you are audited or when you're audited.

[00:09:33] Paul Logan: More eyes on what's going on and a better shared team understanding of what the expectations are can help deal with that in advance so you don't have to go through the process. You mentioned in your article in the Virginia Dental Journal that non-diagnostic quality images could be a common documentation error.

[00:09:55] Paul Logan: Can you expand on that? Is it usually an issue with the equipment and technology, how the imaging is conducted? Do you see some patient conditions that are genuinely difficult to translate into imaging and how do you recommend in those cases that a dentist provides ample supporting documentation, as you were saying, telling the story?

[00:10:15] Dilaine Gloege: So the most common error I see with non-diagnostic quality images is, for example, a periapical image. A proper periapical captures the very top of the crown of the tooth to just below the apex. And sometimes we cut that apex off and the doctor may say, I can still see what I need to see. You don't need to retake the image. It's just fine. But when we cut that apex off, when we're taking that image, the payer or anybody looking at it, they're gonna wanna see the health of the apex before the payer invest in a crown, for example. They need to see the whole picture, and that's not a proper image.

[00:10:59] Dilaine Gloege: So that becomes non-diagnostic quality. The other one is a bite wing that the contacts are not open up, it's cone cut. If the contacts aren't opened up, you can't prove that there was decay interproximally, and that is a non-diagnostic quality image. And sometimes when team members send in claims and they attach an image, if they send in a paper claim, sometimes they will print x-rays and radiographs or photos on regular copy paper or printer paper. When you do that, it loses its diagnostic quality. If you're gonna print 'em, I really recommend that you don't, but you need to use a high quality photo printer with photo paper. The best is to send in the electronic file, the digital image, but those are some of the common errors.

[00:11:57] Dilaine Gloege: We just get in a hurry sometimes in a dental practice and we aren't careful enough. But then there are cases where there's a situation, maybe the patient has a lot of mandibular tori and placement of the sensor prevents you from getting great quality images. Or maybe it's a head and neck cancer patient who has a very limited opening. Ya know look for ways to make sure you can get the best diagnostic quality image, and sometimes you can do that with extraoral images taken on a CBCT machine or a panorex machine. Whatever you need to do to ensure that anybody looking at that can visualize on that image, what you're seeing in the mouth and on the image. Because if you take an image and your chart note doesn't have anything about what you see, then you didn't really support the procedure or your diagnosis or your treatment planning.  

[00:12:58] Dilaine Gloege: For example, if your primary care provider, ordered an EKG. You would not open up your chart note and see EKG results and in parentheses see EKG report. Well, it's no different for us with our radiographs. I need you to tell me in the clinical note, what is seen, heard, felt, measured, and smelled. What did you see on that radiograph based on your clinical professional judgment?

[00:13:29] Dilaine Gloege: So if there's a lot of tori or the patient has limited opening, whatever it is, or what did you see on that radiograph? I need to know about it in your chart note, because the radiograph supports what you documented. It doesn't take the place of documentation.

[00:13:44] Paul Logan: So in, in some cases, a carrier may require radiographs before and after a procedure is performed, and some or all of those may, may not be covered by the patient's dental carrier when those aren't covered or if the patient has exhausted their deductible. What do you recommend for the dentist and their team as they work with patients to help them understand and deal with that situation? 

[00:14:11] Dilaine Gloege: So if you're taking an image that's taken preoperative for diagnostic purposes, that one should be charged. But if you're taking an image, not necessarily because the insurance payer requires it, but because you just seated a crown and you need to take an image to ensure that you seated it properly and that it's seated all the way. That's not diagnostic image, so you shouldn't bill for that image. It's similar to when you're doing an endodonic procedure, you're doing a root canal. We've always had what we called working images, so we have the diagnostic image it's taken preoperative. And then during the root canal procedures, we will take images to check the file length and check and make sure we've got a proper feel , as we go along in that process. So it's very similar to that. We don't charge for those working images for that root canal.   

[00:15:10] Paul Logan: Thank you. And I think you've done a very good job in a short time of laying the theme of every team member plays a role in avoiding an audit and how you can work together, get more eyes on it, make sure everyone understands what the expectations are and how you can tell that story.  

[00:15:28] Paul Logan: Do you have any further resources around proper coding or continuing education on coding. So to to further , that understanding. 

[00:15:38] Dilaine Gloege: Be sure that you update your coding manuals on an annual basis. Coding is changed every year, and the new code set becomes effective January 1st of each calendar year.

[00:15:49] Dilaine Gloege: And the golden rule of coding, no matter which code set you're utilizing, is the doctor must select the code that most accurately describes what is performed or rendered, what services rendered. From the current code set and just the deletion or addition of one single word in a code, nomenclature or descriptor can totally change how you utilize that code in your practice, but it can also change how it should be documented.

[00:16:20] Dilaine Gloege: Because there are coding guidelines written within that code language, and if you are not aware that the code language changed, you may not be documenting exactly what you did. And it has to include the specificity to support every code that you code for the procedures. And this is regardless of insurance. 

[00:16:42] Paul Logan: Right? This is obviously a big complex issue to cover in a brief conversation. Is there anything we didn't get to that you think is important for our member dentists in Virginia to know about avoiding audits and how, as you said in your article, to, to ace them when they do happen? 

[00:17:01] Dilaine Gloege: Just invest in your team, not only in the resources for proper coding and billing, but invest in proper training.  

[00:17:08] Paul Logan: Have someone come in every year, do an update for proper coding, have someone look at your clinical notes and work with your team. Teach them how to implement these internal audits. And it is a team effort because every dental team member has the responsibility to ensure accuracy in our documentation. 

[00:17:32] Dilaine if members are hearing this and would like to follow up what's the best way that, that they could reach out to you? 

[00:17:40] Dilaine Gloege: So you could email me directly you could find me via my website to email me directly tidewaterdentalconsulting.com.

[00:17:49] Dilaine Gloege: You can also connect with me on various social media platforms, Facebook LinkedIn, and Instagram. I'd be happy to connect with you there as well, but you can always contact me through my website and send an email and I'm happy to answer any follow up questions, provide more details. Maybe you have a question, you're thinking maybe my documentation doesn't fully support certain procedures, and you just wanna schedule a complimentary 15 minute call, please reach out to me.

[00:18:21] Dilaine Gloege: I'm happy to assist you.   

[00:18:23] Paul Logan: Thank you so much Dilaine and that will wrap up our conversation today. Again, Dilaine Gloege with Tidewater Dental Consulting and you can watch for her article appearing in the spring issue of the Virginia Dental Journal. Thank you so much, Dilaine. 

[00:18:39] Dilaine Gloege: Thank you so much Paul.