Dental healthcare practitioners work with various third parties to develop opportunities, promote public health and assist with modern commercial realities. This relationship impacts the delivery of dental care to patients and can sometimes present its own risks.

Who are third parties?

Any outside body that can influence the dentist-patient relationship. These include but are not limited to:

  • regulatory authorities (AHPRA and Medicare)
  • private health insurers
  • owners of dental clinics who are not dentists, corporations
  • the public sector (government departments)
  • the dental industry
  • professional indemnity providers
  • funding agencies
  • rating websites.

Why are you being audited?[1]

Frequently, audits commence their life as a request for information or explanation from a third party. The request is often triggered because the practitioner has been identified as a statistical outlier. Third parties collect data to create statistical models, which are used to identify billing trends across the industry. If a practitioner falls outside the industry norms, they may be asked to provide an explanation as to why that is the case.

Alternatively, there may be a random audit, for example by AHPRA in relation to professional indemnity insurance or CPD.

It can also be triggered by a complaint.

What steps can I take to protect myself?

  • Considered oversight of your requirements and obligations – regulatory, private and commercial agreements
  • Documentation and adherence to these requirements
  • Understand that delegation of coding, billing and clinical work does not remove responsibility.
  • MIPS early involvement and assistance
  • Cooperate and follow MIPS’ advice.

DO

  • Understand your regulatory responsibilities and obligations
  • Understand your responsibilities and obligations for all commercial dealings
  • Ensure you understand the terms and conditions under which you are entitled to claim
  • This includes reviewing your HICAPS agreement if you utilise a HICAPS machine
  • Ensure that you have some oversight of the codes being put through on your provider number

DON’T

Be creative in your claiming/code use.

MIPS Resources

[1]Private Health Insurer audits – a reminder to exercise caution and to ask for help (2020). Meridian Lawyers.

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This information is not intended to be legal advice and as such should not be relied on as a substitute. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Should you wish to obtain further information you can review our Member Handbook Combined PDS and FSG or contact MIPS on 1800 061 113. You may need to consider seeking legal or other professional advice about your individual circumstances as appropriate. Information is current as at the date published.

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