Policy on Third-Party Payor Audits, Abuse, and Fraud

Purpose

One of the aims of the Deficit Reduction Act¹, approved by the United States (U.S.) Congress in 2005, was to prevent Medicaid fraud and abuse through an audit process. Despite the good intentions of this law, experts predicted health care providers would see more investigations, enforcement actions, and whistleblower cases and would need to devote more resources toward compliance.² Pediatric dentists play a critical role in the Medicaid program, and there will be negative impact on access to care if providers are burdened with excessive regulations and unfounded audits. Nonetheless, the American Academy of Pediatric Dentistry (AAPD) supports efforts to eliminate Medicaid abuse. Such unprofessional conduct could result in loss of membership status in AAPD.² This policy is intended to help AAPD members understand the audit process, both internal and external audits.