Dental credentialing is the process by which a dentist enters into agreements with insurance providers. Credentialing is paramount for insurance carriers as well as dentists. The process enables the dentist to be compensated for their services and enables the insurance provider to weed out dentists who might not be qualified to give care.
The process of obtaining dental credentials can be complicated and time-consuming. The seamless and effective operation of your dental practice depends on it, though. You can spare yourself a tonne of trouble in the future by taking the effort to comprehend the credentialing procedure.
Once an insurer receives the dental credentialing application of a provider, they review and verify all the information. The process is known as vetting. After the application gets approved by the insurer, the provider participates in the contractual agreement with the insurer and follows the fee schedule, contractual guidelines, and limitations for patient copayments.
The provider's practice history, professional training, education, and licenses get reviewed as part of the credentialing process. The providers are the best to choose among the insurance companies' plans depending upon the competition and other providers' area to understand which insurances they are in-network with or if you are the only contracted provider in the area.
Importance of Dental Credentialing
Dental billing is a mess if the insurance companies receive the claim without the provider's information. That is not good for the RCM, as the claim sits for more days than expected, disrupting the cash flow. It is more complicated if the patient is under the impression that the provider is in-network and later understands as they are not.
It is a time-consuming process, but if done correctly saves a lot of energy. If there is more than one dental provider at multiple locations, then each provider needs separate credentialing at each location.
How to apply?
Every insurance company has its credentialing requirements, but there are some basic standards that all insurance companies follow. The dental provider must have a valid dental license and be in a good position with their state dental board. In addition, they have malpractice insurance and meet all the educational requirements per the insurer. Once you have the credentials, you can apply for dental credentialing through the dental billing company to review and verify the same.
Credentialing and contracting checklist
Dentistry is simply dealing with what the insurers want from you, what your front office can deliver, and the patient's expectations. It can be a struggle to a point when you do everything, and the claims get denied entirely. Without knowing the process, you are out of cash in your dental practice. Dental providers serve patients exceptionally, and therefore getting paid is equally crucial.
Before moving further, your dental practice should know that there is a slight difference between claim rejection & claim denial, although both mean no reimbursement.
Let's look at the top five reasons dental claims get denied and how your practice can resolve them for reliable and consistent cash flow.
Inaccurate Patient information on the dental claim insurance: Claim denials are often due to incorrect patient information. It seems like a no-brainer, but one of the common reasons for prolonging the revenue cycle. It is easy to misspell the patient's name, input the wrong insurance number, transpose digits in the ID number, etc.
Another reason for input error could be that your patient updated some of their information, like employer, name, and address, without informing you. Always confirm the details since their last visit.
Filing an insurance claim after the deadlines: Different insurers have different deadlines for insurance claims, and keeping track of individual carriers is tough. Although, their window has around 60-90 days to file a claim. It starts on the service day. It is best to submit claims as soon as possible to avoid the pile.
It is best to call the insurer company and clear things up to fill out the paperwork and keep a balance between the dental practice and the administrative tasks. To resolve this issue, outsource the dental claim service and get professional assistance from trained billers that help you by taking your claims, coding, billing, and timely filing.
No pre-authorization: Providers know that neglecting pre-authorization can cause the practice and patient money, unexpectedly leading to dissatisfaction. It is one of the top reasons claims get denied, and often providers tend to miss due to the workload given for a certain amount of time.
There are certain appointments, some days before pre-authorization runs out.
Not to overlook, as it is the only way to ensure reimbursement and get paid for the rendered service.
Not reviewing the patient's coverage: Sometimes, the provider fails to cross the insurance plan benefits. If a patient comes into your office claiming that they have dental insurance. It is still a good practice to ask your staff to have a run-down of the coverage before the insurance company denies the claim stating it is not a covered benefit.
Unnecessary denials affect your organization's revenue cycle because the insurer will not pay for the non-covered treatment, and your patient will be surprised by the bill. To avoid this confusion, review the patient's file before they enter the office for updated information and active dental benefits.
Ignoring the Insurance Verification process: Performing accurate insurance verification is an indirect revenue generator. Sometimes the provider goes for the treatment without double-checking the patient's claim. The insurance companies deny the claim due to the non-verification.
That can be a loss in revenue which any dental practice does not want again and again. Moreover, verification helps in preventing denials and fraud.
Insurance verification ensures that the submitted claim is correct. The submitted documents are cross-checked, thereby eliminating the chance of denial. Therefore, providers must not ignore this process.
Nobody likes to work on denied claims as it increases time and energy. Communication with the patients and the insurers, well-trained staff, professional coders & billers can substantially minimize the risk of claim denial and the headache that goes hand-in-hand with the claim.
To understand the credentialing specialist role, first, you need to understand dental credentialing. The dental provider and the insurer enter into a contract that provides the best patient care with a continuous collectible rate.
The credentialing specialist ensures that the provider and the healthcare facility, like hospitals, Medicare, commercial payers, surgery centers, and Medicaid, comply. Credential specialists maintain all records related to staff credentials and insurance companies.
Ensure that all the necessary documents are there in the claim. That is where dedicated specialists come into play. They inform the dental practice staff and the insurer about the changes in the contracts and the policies. A benefit is that they are familiar with programs like word processing, spreadsheet, etc., as most of their work gets done through computers.
Experience
The National Committee of Quality Assurance (NCQA) provides guidelines, including documentation and provider credentials. It is mandatory to apply NCQA standards. Later, in the field, you may pursue the Certified Provider Credentialing Specialist professional designation from the National Association of Medical Staff Services after three years of experience.
For proper reimbursements, dental coding plays a crucial role. Unlike medical billing, it involves a different set of codes that is often confusing and critical. Current Dental Terminology (CDT) codes in coding achieve uniformity, specificity, and consistency. These codes get compiled by ADA (American Dental Association), which helps dental procedures accurately for better claim submissions.
These are a series of codes used for different dentistry and oral health operations procedures. Each procedural code is a five-digit alphanumeric code that always starts with the letter "D" followed by the numbers. Few procedures enable descriptions so that the provider's concerns can be rectified and addressed by the types of services rendered.
CDT codes are categorized in the following way:
These codes get assigned by dentists, specialists, hygienists, and generalists as it restricts the use of the dental codes.
It is complex to understand the differentiation between the usage of CDT and CPT codes and is primarily dependent on the type of insurance that is availed and to which the claim is billed.
Health professionals have three types of options for insurance coverage for billing:
You must apply the CDT dental codes if you submit dental benefit claims as an in-network or out-of-network provider or if you conduct electronic communications or transactions covered by HIPAA.
The CDT Code has been established by the U.S. federal government as the national terminology that must be used when submitting dental treatment claims to third-party payers. Additionally, CDT coding has been established as a compulsory standard for the electronic communication of dental procedures.
For example, if the patient has a cyst or ulcer in the gums and the same is incised and drained in the provider's office, the procedure can be billed as either dental or medical.
Dental claims use the J400 form, whereas medical claims are presented on their claim form (the CMS 1500 form). J400 is mainly designed to accommodate all the dental information necessary dental information. Dental claim forms must include the following dental information:
Provider credentialing is the process of verification of competency, and if the provider wants to start early, the payers won't accept the application to begin credentialing. It typically takes 3 to 6 months or longer as some plans do not want to expand their payment exposure.
It can be tricky that providers cannot see the patients with the insurance plans by the time credentialing gets done, as they will not receive reimbursement for any services rendered. The patient cannot get treatment from an out-of-network provider if they carry insurance because the services will not get covered.
Therefore, the process can lead to revenue loss if approached carelessly or incorrectly. But on the other hand, the credentialing system can add benefits like increasing patient base, more services offered, free advertising network through the insurance company, preferred provider by the insurance company, etc.
What to do while it is affecting the business?
Provider credentialing regulates the qualification and ensures the credibility of the provider that the patient has chosen. Credentialing happens at hiring in an organization or adopting a new insurance provider. Hence, there is no room for errors in treatment costs and diagnosis.
It is a quality assertion process to optimize the incidences of dental errors and accomplishes the goal of the best care your patients deserve. In addition, it includes the verification of the provider's education, license, experience, certifications, and residency. Credentialing services assure that the patient will receive the proper care and improve revenue cycle management through receiving timely reimbursement for seeing patients.
Provider credentialing prevents claims denial and helps expand the patient base by coming on the insurer panels. However, applying and maintaining the up-to-date information with the insurers is a time-consuming process and, if not managed successfully, can lead to revenue leakage, delay in insurance payments, decrease in patient referrals, tedious paperwork, increase in denials, and a not-so-good impression on the payers.
Let’s begin with knowing what CAQH is! It stands for the Council for Affordable Quality Healthcare, a not-for-profit collaborative alliance of the nation's leading health plans and networks. Its mission is to improve the accessibility and quality of healthcare services for patients and the reduction of the administrative burden for healthcare providers and their office staff.
In simple words, CAQH is an online database that contains information on credentials. Practitioners provide insurance companies with their self-reported demographic, educational and training background, employment history, malpractice history, and other pertinent credentialing data.
Let us have a detailed look at CAQH credentialing.
Health plans and credentialing providers can pay to access the CAQH, a massive database. To simplify the credentialing process, the Council for Affordable Quality Healthcare CAQH collects credentialing information about healthcare practitioners and makes it available to health plans and other healthcare bodies.
Consider the certificates or licenses you now hold that automatically expire periodically. You can upload this pdf file into CAQH, confirm its accuracy, and give all the insurance companies access to the file instead of giving each company an updated license.
By removing a large portion of the paper-based enrollment procedure involved with insurance companies' network enrollment and facility privilege applications, online accessibility to this information is intended to lessen the administrative load.
Many insurance providers demand CAQH; there are several exceptions to this rule, as a few states maintain systems that operate similarly to CAQH. There is still a solid reason to enroll with CAQH even if your state has its system because some national organizations initially use the state system but eventually prefer CAQH.
Both basic credentialing and payer recredentialing involve CAQH; this implies that you must update the database. Payers may use your CAQH portfolio when you initially obtain credentials from health insurers and transmit them into their network.
It increases efficiency by reducing the number of repetitive applications or requests for information that must be handled, in addition to serving as a mandate in the majority of states.
Dental Credentialing is very vital in today’s competitive environment. With a multitude of dental practices being open, patients prefer going to a dental practitioner who is in-network or credentialed. Opting for dental credentialing widens the potential patients within an area as well as bolsters the visibility online & in-network, which in turn buttresses the revenue cycle management (RCM). Dental Credentialing is a complex process and has to be done with the utmost care and focus. This article mentions the errors and mistakes that a dental practitioner must avoid for explicit dental credentialing.
Inaccurate credential verification: Medical credentialing process requires accurate verification of the dental practitioner’s educational qualifications, employment history, training certificates, residency, and licenses, along with any certifications issued by a board in the provider’s area of specialty. Verification of such important documents requires a team of prolific experts who are well-versed with the dental healthcare system as well as insurance companies’ protocols. The biggest and most common mistake that dental practitioners commit is not delegating these tasks to adequate personnel. The error of not opting for adequate staff for the dental credentialing process results in multiple errors. This further leads to insurance companies rejecting the application submitted by the dental practitioner, hence stemming the revenue cycle. Moreover, the evaluation of appropriate staff for dental credentialing can be a burdensome task. This issue can be vanquished by outsourcing medical credentialing and billing services from a renowned company. Such companies have a specific team of experts handling each step of the process with accuracy while keeping errors and mistakes at bay.
Insufficient provider enrollment applications: Accurately filling the provider enrollment application is vital for the dental credentialing process. This is because even missing the response N/A (for the sections that don’t apply to your dental practice) can lead to application denial as the insurance companies treat such applications as incomplete. Therefore, filling each and every section is extremely important. To avoid such errors, the team handling the dental credentialing process should dedicate their time just for the same with undivided focus. However, when the staff of the dental practitioner handles this process, they also get involved in other clinical tasks, making the process more prone to above mentioned manual errors. On the other hand, dental credentialing companies use advanced software handled by experts, which in turn makes the complete process error-free.
Outdated Information: Dental Practitioners are required to renew their dental license as well as their dental credentials periodically. Staying up to date with the board of dental licenses and certificates is the key to achieving foolproof dental credentialing. Various studies have found out that 85% of dental credentialing applications have either inaccurate, missing, or outdated information. Every small detail such as a change in address, phone number, etc. is required to be updated, which, when done otherwise, leads to the dental credentialing application rejection by the insurance companies. The most appropriate solution for such issues is to compile and manage all the necessary documentation together and update them timely. However, this can be an issue for dental practitioners as they are already burdened with other clinical tasks and dental services. In such scenarios, outsourcing dental credentialing and billing services help tremendously. Such companies are skilled in the management of necessary documents as well as in updating them regularly.
Deadlines: Medical credentialing can take up to 90 days to 6 months. As it is such an intricate process, when handled by in-house staff, deadlines can be missed in order to take care of all the above-mentioned points and avoid errors. However, missing deadlines can delay an already long process directly, impacting the revenue cycle. Outsourcing dental credentialing services can save dental practitioners from encountering such issues. While maintaining error-free process management, these companies make sure to submit your applications well within the deadline. Dental credentialing and billing companies like Capline dental services are renowned establishments that are trusted by thousands of dental practitioners across the United States. These companies support dental practitioners with advanced resources and profound experts, ensuring streamlined, smooth, and efficient revenue cycle management (RCM).
CAQH (Council for Affordable Quality Healthcare), is an online data repository of credentialing data that stores information about medical professionals including their work history, training, education demography, malpractice history, and other relevant or applicable information required for healthcare providers, which is also applicable for a few dental insurances as well.
CAQH plays a crucial role in the credentialing process as it allows the insurance firms to access your details and documents such as license, DEA certificate, and malpractice policy that regularly expires without your notice. Instead of providing your documents to different payers, you can simply upload the attested copies into CAQH and allow the payer to access your information.
CAQH is used by 90 percent of the National Health Insurance Providers and is a requirement for their enrolment. However, government insurance companies do not use CAQH.
Use CAQH for Credentialing
CAQH is used for primary credentialing and payer re-credentialing. It’s a database that needs to be revised regularly on your part. The CAQH Credentialing process involves the following steps:
Now, after performing the above steps, you can start the credentialing process with the insurance companies as they will be able to access your profile along with the documents that you have submitted to support your application.
Create Profile on CAQH
You can follow the steps below to complete your profile on CAQH.
STEP 1: Get the CAQH ID
Before starting the credentialing process with an insurance provider, you must create your CAQH profile. After creating and submitting the profile, you will receive your CAQH provider ID. In case you don't receive it contact the CAQH ProView support.
STEP 2: Keep all your Documents and Records ready
Here are some details that you need to fill out for the CAQH:
You would also need the following materials to complete your application:
You may need to submit the certificate from Drug Enforcement Administration (DEA) and Certificate of Controlled and Dangerous Substances (CDS), if applicable. Also, keep the following things checked so that your application is neither delayed nor denied:
STEP 3: Fill in your profile
When all of your documents are ready, it's time to finish your profile at CAQH website. Filling the online application is advised as application on paper is extremely long.
When all the necessary information has been submitted, you will be notified by the website to review all the information and verify the same. You will get a message about the completion of your profile. You can either allow any insurance firm to access your profile or manually choose specific insurance firms to grant access to your profile, as CAQH gives you these two options to choose from. The first option is generally good to go with if you want to have as many panels as you can, while the second option is better if there are one or two organizations that you would like not to work with.
While you only need to complete your profile once regardless of how many insurance panels you apply for, quarterly you will be asked to test the details again. So, don't lose any of your application details and respond quickly to such requests, as failing to do so will cause insurance providers to refuse to pay claims. On average, it takes just a few minutes to complete.
STEP 4: Re-Attestation
After your application is complete, CAQH will notify you quarterly to re-attest all the information and update the supporting documents. This allows the participating organizations accredited by a provider to access profile information from CAQH based on their various periods of re-credentialing.
If a participating CAQH entity wishes to access information about a provider, it will not be available until the provider completes the process of re-attestation.
Credentialing has always been one of the biggest challenges when it comes to running a successful dental practice. It ain’t an easy ride, however, it’s important to keep your practice smooth and streamlined to enjoy a steady revenue stream. The credentialing experts at Capline understand your situation and know that you already have a lot on your plate. Therefore, we take the burden off your shoulder to give you more time for patient care. We totally understand how stressful it becomes to coordinate with insurance providers. At Capline, we can take care of all the paperwork related to credentialing and help your practice with consistent cash flow and even better patient care.
To identify the right time to outsource credentialing, here are a few things that must be considered:
Busy Staff
Collecting all the important details like insurance, billing address is quite complicated and strenuous activity. If your staff is busy doing these tasks rather than attending patients, this could be a major red flag and hinder your practice. By outsourcing provider credentialing, your staff will have more time to focus on patient care and other major responsibilities.
Lack of Experience
If there are loopholes in the way your practice functions, it could be detrimental to your practice. It is very important to keep up with the changes in industry because if your staff is not updated about best insurance providers, regulations and current practices, you will certainly be losing out on revenue.
Outsourcing Dental Credentialing process to us ensures that this does not happen. Our expertise and knowledge is centered on staying updated with the current industry practices.
Overburdened Staff
There are many practices that overburden their staff with so many duties related to credentialing and paperwork. This, in turn, deteriorates the efficiency of staff, leading to their being overextended. Outsourcing credentialing service to Capline takes the stress out of this burden. We make use of specialized process that leaves your staff with more time to devote to patient care and improvement of the patient experience.
By outsourcing credentialing services to us, your staff will have the time to offer the best care, support and service to your patients. So, if you want to experience happier patients, increased revenue, timely collections and better patient care, outsourcing will be the best option. To know how our credentialing experts can help you, schedule a call with us today.
