In Dental Billing

So, you finished dental school, joined or bought a practice and you’re sitting there saying to yourself, “what’s next?” The majority of dentists, at some point in their career, question their fees, the patients they want to serve, and their vision for their practice.

You find yourself struggling with the delicate balance of not wanting to have the reputation of being the most expensive, but also want to be fairly compensated for your quality work and time. The bigger question that follows this conscious train of thought is, “Who should I be credentialed with? All insurance companies? Some of them? None of them?” 

Fortunately, there are outsourced dental billing companies, like Dental ClaimSupport, that specialize in answering these questions for you. With years of credentialing experience, our team came together to help you make the best decisions for your practice in regards to credentialing and network participation. We feel the information below will not only make you more comfortable with the networks you choose to participate with, but will also leave you with a better understanding of the credentialing process. 

 

What is dental credentialing?

Dental credentialing is when a dentist enters into an agreement with a dental insurance company (in-network) by accepting the fees and provisions of the contract to access a large network of patients.

The credentialing process is quite the venture and can take anywhere from 90 to 180+ days to complete. Various forms of documentation are required during the vetting process to ensure servicing the patients in the network is in your best interest. 

Although there are perks to becoming an in-network provider for a specific insurance company, there are also specific guidelines within the contract that you need to be comfortable with prior to signing. Things such as audits, services that can not be billed to the patient regardless of necessity, and bundling of services to reimburse at a lower rate may not be favorable long term. 

You may be asking yourself, if the insurance company is going to dictate the dentistry I can provide and what I can bill my patients then why would I go in-network with them? Great question!


Why should I credential with a dental network?

Simply put, by directly contracting with an insurance company you will increase your overall patient base.

Being in-network can act as free marketing for your practice by listing you on the insurance company’s website as a preferred provider. Meaning, as patients search for providers in their area, you’ll show up. This provides a source for new patients.

The majority of patients that pay for dental insurance do not want to incur extra expenses for dental care that they deem to be ‘free’ (the majority of preventative services). If the option is to see an in-network provider with zero out of pocket expenses for a cleaning or going to an out-of-network provider and run the risk of paying anything out of pocket, most patients are going to choose the in-network option.

A patient’s ability to accept proposed dental work will also increase with network participation. The reduced fees you agree to accept per your contract are more appealing to patients when they know their insurance will be paying a portion. I’m sure you’ve heard it at some point throughout every day, “What will my insurance cover? What will I have to pay?” when discussing treatment.


What’s next if I want to become credentialed with a specific dental network?


Read everything and still want to move forward? Great!

Here’s what a typical outsourced dental billing company that specializes in credentialing will do for you. First, they will help you decide which insurance company(s) best fit your practice based off of previous conversations centered around your practice goals (grow your patient base, increase reimbursement, etc.). Once they have come up with a set list of networks, they will call and find out the specifics of your status.

You may, unknowingly, already be in-network under a different Tax ID. This commonly happens when a provider leaves one practice and joins/opens another. If this is the case, it also dictates the paperwork that you will need to complete to move forward: re-credentialing vs. initial credentialing.

Once you’re deemed to be ‘in good standing’ (not being subject to any form of sanction, suspension or disciplinary censure) with the insurance company, and they have determined whether this is a new application or an update to an existing contract, they will move forward with the appropriate paperwork.

 

What information will the outsourced dental billing company require?

For an initial application, the credentialing specialist will need quite a bit of information from you: Legal name, date of birth, social security number, degree (DDS vs DMD), National Provider Identifier (NPI-1), copy of your dental license, curriculum vitae, Drug Enforcement Agency (DEA) registration number, and proof of current malpractice/liability insurance.

And if that wasn’t enough, they will also need the following about your practice: Legal office name and DBA, a signed W-9 Form, Tax Identification Number, physical address, billing address, phone number, fax number, and Group National Provider Identifier (NPI-2), if applicable.

If any of the above information has not been created, the credentialing specialist will more than likely assist you in that process as well. On a positive note, once all of that information is provided initially or obtained by means of accessing a one-stop-shop like the Council for Affordable Quality Healthcare (CAQH) ProView, it should not be requested again from you. 

The American Dental Association (ADA) teamed up with CAQH by creating a platform for all U.S. licensed dentists to enter and share their professional and practice data with dental plans and other healthcare organizations. This service reduces the administrative burden of the credentialing process and can be quite the life saver.

The quicker the credentialing specialist receives all the information above, the quicker they can get started with submitting your application.

 

How long will the dental credentialing process take?

There are many variables that go into the length of the credentialing process. If you’re simply being re-credentialed, this can be accomplished rather quickly.

The initial contracting however tends to take quite some time to complete and varies greatly on the rate at which the insurance company or government funded, such as Medicaid, CHIP, etc. plan is processing applications. Outlined below is the typical time frames for various credentialing options.

  • Direct Contracts (Processing time frame: 30-180 days from the date the application is submitted)
    • Direct Contracts are when you are contracted with a specific network and you utilize their fee schedules directly.
    • Types of direct contracts include:
      • Preferred Provider Organization (PPO)
        •  (30-180 days from the date the application is submitted)
      • Healthcare Management Organization (HMO)/Dental Health Maintenance Organization (DHMO) 
        • (30-180 days from the date application is submitted) 
      • Medicaid 
        • (90-180 days from the date application is submitted)
  • Direct Contract with 1 large insurance company that shares its network with Third Party Administrators (TPAs) also known as an Umbrella Network
    • For example, you may be contracted with Dental Health Alliance (DHA) directly, but it shares it’s network fees with other plans like Aetna. So, although you do not have a direct contract with Aetna, your name populates in-network with Aetna by means of the DHA network. The lower applicable applies in this scenario.
    • Direct contract- (30-90 day time frame)
    • TPAs to utilize network
      • An additional 30-90 days after the direct contract is accepted with the main insurance company**
      • All TPAS have a choice of accepting the fee schedule and contract or denying completely
        • If denied-we can do a direct contract with that particular insurance company

 

How will I know when I’m completely credentialed?

It’s impossible to know exactly what the approval process looks like, but we can tell you about what ours looks like. This will give you a good overview about what you might be able to expect.

After all the paperwork has been submitted, we call and verify that it was received and whether or not it is currently being processed. If it was received and anything was missing or deemed ineligible, etc. we will be sure to get that information to the provider relations department of the insurance company as soon as possible.

During this initial call, we will also ask for an estimated timeframe of completion. Similarly to the time frames listed above, the representative in provider relations will give us the same estimated time frame for completion. All conversations are notated and reviewed by your credentialing team on a weekly basis.

We also contact provider relations roughly every 30 business days to check the status of the application. All communication with provider relations is documented with a reference number, the representative’s name, and the date of the conversation. This helps us keep a detailed communication log of your application and all pertinent information. This information will be shared with you once it is received by provider relations.  

Once contracted, a letter or email will be sent to the office along with your ability to access your current fee schedule of the agreed-upon fees with the effective start date of your contract. Congratulations! You are now in-network! What’s next?

 

What should I do after I am credentialed?

You want to make sure the new fees you’ve agreed to are in your practice management software. Whether you pay to have an outsourced dental billing company update your fee schedules or you choose to do them yourself, this is a vital step in ensuring accuracy within your dental practice. 

This is also a huge benefit for your current and potential patients that fall under the insurance company in which you are now credentialed with. The more accurate your fees and estimates for necessary dental services, the more likely patients will agree to schedule and have the work completed. 

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