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A payer audit is a request to justify claims you have already been paid for. The response determines whether you keep the money. Deadlines are strict, first responses matter, and extrapolation can turn a small sample into a very large demand. Engage counsel before responding to anything beyond a routine records request. For a subpoena, a civil investigative demand, or any government inquiry, stop and call counsel before responding at all. What you say first shapes everything after. See When to call a lawyer.

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Know which kind you have

SIU, MFCU, UPIC, OIG, and DOJ are different in kind, not degree. These are fraud investigations. Treat any contact from them as a counsel matter from the first letter, including the decision about what to produce. Dentistry’s enforcement record shows why: every major dental False Claims Act case grew out of Medicaid claims data and insider reports, and the paying defendant was usually the management company.1

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What dental audits target

Chart audits often concentrate on procedure families that appear in the enforcement record and OIG outlier analyses:2
  • Scaling and root planing. Payers commonly expect full-mouth periodontal charting with pocket depths and radiographic evidence of bone loss. They may scrutinize SRP billed on a healthy mouth or all four quadrants billed on the same day without supporting documentation.
  • Crowns. Preserve radiographs showing the tooth before preparation and the narrative explaining why a filling would not serve.
  • Pulpotomies and stainless-steel crowns on children. The record should support the diagnosis and treatment, including radiographic findings where applicable. Allegedly unnecessary pulpotomies appear in several Medicaid dental matters.1
  • Surgical-coded extractions. Settlements have addressed simple extractions billed as surgical procedures.
  • Behavior management and anesthesia codes on pediatric Medicaid claims
Radiographs often carry much of the evidentiary weight in a dental chart audit. The auditor compares the images with the code billed. Preserve diagnostic-quality images of the correct tooth and date, indexed so staff can retrieve them by claim. A note that says only “deep decay” may not support the service if the expected image is missing or unclear.

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Steps

1

Log it the day it arrives

Date received, payer, auditor, claims at issue, deadline, and the response method required. Assign an owner immediately.Audit letters may go to a location’s front desk or an outdated credentialing address. Monitor the correspondence address recorded with each payer and dental benefit administrator.
2

Calendar the deadline with a lead time

Missing an audit deadline can result in an adverse determination without consideration of records that might have supported the claims.
3

Determine whether counsel is needed

4

Pull the records requested, and only those

Send exactly what was asked for, for exactly the claims and dates specified.For each claim, typically: the clinical notes supporting the service, the radiographs, intraoral photos, and perio charting for the procedure billed, the dentist’s signature and credentials, the predetermination or preauthorization where one was obtained, and the itemized ledger.
Do not send more than requested. Extra records expand the audit’s scope and can surface issues on claims that weren’t under review.Do not alter existing records or create a misleading late entry. Preserve the record as it existed when the request arrived. If a note is unsigned or an addendum is permitted and appropriate, involve counsel and follow the record system’s audit-trail requirements.
5

Review before sending

Have a dentist read every chart and film against the CDT code billed. You want to know what the auditor will find before they find it.If you discover a genuine overpayment, that is an identification, and for Medicaid the 60-day report-and-return clock starts. Discuss with counsel how to handle it in the context of the audit. See Report and return overpayments.
6

Submit properly, with proof

Use the required method. Include a cover letter indexing what you sent, organized by claim. Number the pages, and label every radiograph with patient, tooth, and date. Keep a complete copy of exactly what you submitted, and retain delivery confirmation.
7

Respond to the findings

Findings letters often provide a short appeal or rebuttal window. Review each disputed claim individually. Check the auditor’s calculations, the images, and the treating dentist’s contemporaneous documentation. A supported rebuttal may reduce the demand.

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Extrapolation

The mechanism that turns a modest audit into an existential one. An auditor may review a sample of claims, calculate an error rate, and extrapolate it across a larger claim universe. A 30-chart sample with a 40% error rate can therefore produce a demand covering thousands of claims. Review both the underlying determinations and the sampling and extrapolation method. Grounds on which extrapolation is commonly challenged:
  • Sampling methodology, was the sample properly random and statistically valid?
  • Universe definition, were the claims in the universe genuinely similar to those sampled?
  • Sample size, too small to support the precision claimed
  • Error determinations, if individual errors are overturned on appeal, the extrapolation must be recalculated
  • Statutory and program requirements for when extrapolation may be used at all
Extrapolation challenges are specialist work requiring a statistician as well as counsel. If extrapolation is on the table, the cost of expert help is almost always less than the demand. Do not attempt this alone.

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While the audit runs

  • Do not change your billing practices in a way that looks like concealment. Do fix genuine problems, and document that you fixed them.
  • Preserve everything. Institute a litigation hold if counsel advises.
  • Limit internal communication about the audit; discuss through counsel where privilege matters.
  • Plan for the cash-flow effect. Prepayment review may delay reimbursement while the practice continues operating.

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After it closes

1

Root-cause every sustained finding

Documentation gaps, missing or non-diagnostic radiographs, coding errors, missing preauthorizations, or an actual compliance problem.
2

Fix the process, not just the claims

3

Consider whether the finding implies broader exposure

If the audit identifies a systematic error, similar claims outside the audit period may also require review. For Medicaid, that can trigger an overpayment analysis. If the finding concerns per-provider utilization, such as SRP or pulpotomy rates, compare it with the monitoring in the CPOD self-audit. Work with counsel on scope and response.
4

Document the remediation

A demonstrated corrective action is what reduces exposure on the next audit.

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Verify it worked

  • Audit logged with owner and deadline on arrival
  • Correspondence addresses monitored, per payer and per location
  • Counsel engaged where the type warrants it
  • Exactly the records requested, nothing more
  • No records altered or created after the request
  • A dentist’s internal review completed before submission
  • Radiographs labeled and diagnostic; indexed cover letter; complete copy retained; delivery confirmed
  • Findings reviewed claim by claim
  • Extrapolation challenged with expert support where applicable
  • Root causes fixed and documented

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Sources

  1. The DSO enforcement tracker collects agency sources for dental False Claims Act matters involving pulpotomies, stainless-steel crowns, extraction coding, scaling and root planing, and management-company liability.
  2. HHS OIG, Questionable Billing for Medicaid Pediatric Dental Services (2014–2015 series: New York, Louisiana, Indiana, California); CMS, Medicaid Compliance for the Dental Professional (cataloguing unnecessary services, upcoded extractions, and behavior-management codes as the dental risk areas).
Last modified on August 21, 2026