When your dental practice hires an additional dentist, you must be aware of several critical actions that must occur to receive proper reimbursement for the newly hired dentist’s services. Newly hired dentists must still be properly credentialed and enrolled in your practice’s insurance plans. Learn the consequences of not credentialing, the steps in the process and how to streamline.
What Are Provider Enrollment and Credentialing?
Provider enrollment into dental insurance plans your practice contracts with allows the enrolled dentist to provide in-network services to the plan’s members. Before enrolling practitioners in health plans, the insurance companies independently credential providers. Credentialing refers to the health plan’s process of obtaining, verifying and reviewing the dentist’s professional qualifications to provide services. Only after the credentialing process is complete can the dentist be granted participation privilege status in the health plan. If the practitioner’s application for credentialing is approved, then that practitioner is credentialed with the health plan and enrolled as an in-network dentist for its members, who are assured that the contracted professional has met the appropriate licensure and expertise requirements.
The information gathered and assessed by the insurance plan relates to professional licenses or certifications, education and experience. Required documentation varies slightly by dental plan but at minimum typically includes the collection of diplomas, professional licenses, malpractice history, detailed curriculum vitae and completed enrollment application. Most of these qualifications will undergo primary source verification, which means the dental plan will contact the original source or approved third party to confirm the validity of the qualification. For example, the plan would confirm the dentist is licensed by verifying that license with the state dental board.
Why Must Dentists Enroll in Insurance Plans?
A dentist must complete the health plan’s credentialing process and be enrolled in the plan before providing services to that plan’s members. The process typically takes about 90 days but can extend up to 180 days in some circumstances. During this time, you might be tempted to simply bill the new dentist’s work under the name of an already enrolled dentist. Resist the temptation. Not only is this practice considered unprofessional, but not providing accurate information on the claim form is a fraudulent billing practice.
When submitting claims to insurance plans for reimbursement, you must indicate the treating dentist. The American Dental Association claim forms include areas for entry of the billing provider’s details as well as the provider who rendered the services. Your practice’s information belongs in the billing provider section. The treating dentist’s information belongs in the rendering provider section.
The consequences of not enrolling with insurance companies could be costly. Your practice might not be paid timely or paid at all for treating plan patients. Those patients might be charged higher out-of-network charges, which are harder to collect and impact dental practice’s business operations.
What Are Recommended Best Practices for Streamlining the Credentialing Process?
Begin Early
Credentialing should begin as early as possible to avoid unreimbursed claims or the hassle of having to schedule a new dentist’s appointments according to patients’ insurance coverage. Include insurance plan enrollment requirements in the associate agreement with the new dentist, and obtain that dentist’s documentation as soon as the dentist agrees to join your practice.
Organize Documentation
The completeness and accuracy of the required documentation are critical in timely credentialing. Even a seemingly insignificant omission of a year on a curriculum vitae can delay the process. Compile all pertinent information in a central location for easy access as needed.