The dental credentialing process might appear simple, but it can be challenging. It is also a time-consuming process. A few errors committed by the team can result in serious consequences.
One of the major consequences is a lack of payment by the insurance organization.
Services rendered to patients will not result in a timely reimbursement, and this can impact the financial health of the practice.
There are manifold benefits for a dental practice to get contracted with an insurance organization. The practice can get access to potential customers from the organization’s subscribers. These potential customers have availed of insurance plans for themselves and their families.
Credentialing can also act as a marketing tool for a dental practice. It is highly effective, and sometimes a dental practice can just join a network, and this could be the only marketing needed to garner patients.
One needs to note that any insurance company will consider reimbursements and payments to a dental practice only after the credentialing process is complete.
While the dental team can continue with operations, they will not be able to get paid by the insurance company. Dental practitioners who are not credentialed can only engage in patient billing, as they will not be reimbursed by the insurance company.
The credentialing process appears simple, but a lack of experience and expertise can lead to avoidable situations. A few errors to avoid are as follows.
Avoid applying to various insurance companies simultaneously.
Many practices, especially newly established dental practices, are excited to talk to patients and tell them about being in-network with their insurance companies.
While the intent is to rake in more money and patients and money, one must also get practical and realistic.
Getting loaded with many applications to insurance companies can work negatively against the practice. It may have to consent to a lower fee schedule. If a practice enrolls with an encompassing umbrella of payers, it could end up in-network with not well-recognized insurance organizations that levy lower fee schedules. It is possible that even an individual insurance company could demand a lower fee schedule. Hence, the practice must carefully decide on selecting the right insurance companies based on the terms and how it can impact profitability for the practice.
The practice can also get more business that it can effectively manage. When schedules are tight and the dental team is stretched to perform to expectations, patient care might face a setback. The patient’s experience can suffer; collections might also get affected, and the practice might eventually lose more business.
When the team needs to work swiftly, there is a high probability of witnessing an increase in the number of errors. A team that has a scarcity of time will find it tough to handle collections at a minute level. It might not act promptly on denied claims or downgraded payments. Work pressure can also cause a high staff turnover. These are typical problems faced by a practice when it accepts a vast number of insurance companies.
A fee schedule is a list of services and procedures covered by insurance companies, along with their agreed-upon in-network rates that the dental practice will receive. The fees are used to compute the maximum amount that a patient can be billed, as well as the maximum amount that can be paid based on the patient’s insurance plan.
Some dental practices accept the first fee schedule offered by the insurance company. This is one of the common credentialing mistakes that can cost a practice significantly. The practice must carefully review the reimbursement schedule before signing the contract. It can also utilize the services of a skilled negotiator to craft a fee schedule that greatly benefits the practice.
Some insurance companies are usually ready to negotiate the fee schedule with the practice. A few insurance organizations might adjust some prominent 20 CDT codes instead of raising costs for all services and procedures.
It is critical for a practice to know the fees that an insurance firm can be flexible with and can address all fee-related questions accordingly. The insurance company might agree to certain demands. This can yield a positive return for the practice over time.
Many practices do not undertake a thorough analysis of their service potential with prevalent insurance firms. A dental practice is more than just a finite space that delivers patient care with boundaries. It needs to be in sync with the catchment area, its service offerings, and patient demographics.
Before commencement of the credentialing process, one has to study the demographic strata around the practice and the possible size of potential customers who can be attracted to the practice. One needs to know the prominent insurance firms successful in the area and correlate them with the service offerings of the practice.
Failing to do such an analysis can backfire, as the practice might get calls for appointments from potential patients by being a local player. But these patients might shift to another practice if their insurance plans are not accepted. The practice must ensure that it is accessible to most insured patients in the vicinity.
An easy way to accomplish such a task is to do a pilot study of popular practices in the area and identify which insurance firms they network with. One can then prepare a strategy accordingly. If a practice is the only one in the area, then it is likely that accepting popular insurance firms in the nearest bigger locality can work well for the practice.
The commencement of the credentialing process at the earliest is critical as it can take several weeks or months for an approval to be attained by the practice. Many practices do not start early and hence miss out on potential revenue.
Since the process takes time, the application should begin much before the new dental practitioner’s start date. The team must begin the process of getting an in-network contract as soon as hiring has been confirmed, and not wait for the dentist’s first day of work.
The credentialing process generally takes at least three months to complete and can even extend to six months. This is the period during which a new member cannot get paid in-network for services rendered. Starting early can help the practice avoid extended delays in becoming in-network with insurance companies.
If the practice files a claim without being in-network with an insurance firm, then all the respective claims will be rejected and will have to be billed to the patient. Before getting credentialled, patients will have to pay out of pocket, or the practice might have to turn away patients. It is thus important not to miss out on revenue and a potential customer base.
Very often, dental teams send claims with incorrect data about the provider. This can be a major offence and considered to be a potential fraud.
Since the credentialing process takes time, a fully credentialed dentist might put down the NPI number instead of the associate dentist who has performed the procedure.
This is like conveying to the insurance organisation that a professional who did not perform a procedure, did perform a procedure. This can be considered a fraud since payment has been accepted by the practice based on wrong provider information.
Legitimate insurance claims for services rendered by the new associate are possible only by getting credentialed, and services performed before getting in-network status would be considered out of network.
The dental credentialing process must begin early through a streamlined submission procedure. The practice needs to proactively prepare all documents for the process as soon as a new hire has been confirmed. The practice must make sure that the submission is accurate and complete.
