Every industry faces challenges. Maintaining high quality in the dental industry is the key to delivering excellence to patients. With no room for treatment errors and a focus on cost-effectiveness, dental credentialing emerges as a necessary process.
Credentialing is a quality assurance measure that reduces errors by thoroughly vetting educational qualifications, licensure, training, and past practice history. This critical process occurs before hiring dental care professionals or engaging with new insurers.
Credentialing guarantees that patients receive treatment from skilled practitioners. Likewise, in dental care facilities, hiring qualified professionals ensures harmonious quality care and reduces the risk of breach. Insurers benefit from having professionals, which helps maintain treatment trajectory. For professionals, having credentialing with a network of payers promotes a thriving practice.
However, no dental practice wants delayed payments, dissatisfied patients, claim denials, and lost revenue.
Dental Credentialing:
- Provider credentialing confirms professionals have the right qualifications, relevant experience, and active license before seeing patients.
- Privileging involves obtaining official approval for specific treatment procedures and confirming the expertise.
- Enrolment is getting credentialed by insurance providers, followed by negotiations for contracts that facilitate timely reimbursements and payments.
The process typically follows: completing the credentialing application and collecting all essential documents. That is essential for ensuring a smooth enrollment process and for updating the billing system with the new insurance provider.
Dental Credentialing Billing Inaccuracy for Permanent:
For accurate provider billing, the practice should pay meticulous attention to the payer contracts when billing for non-credentialed providers.
- If the new provider is not taking over the role of an existing one and the dental plan mandates that only credentialed practitioners deliver services, the practice cannot bill for any rendered services by that provider.
- Breach of the contract because of the non-credentialed practitioner or a credentialed substitute. It comes under a violation, even if the contract is in the practice name.
- It is to recognize that some insurance plans may require only credentialed practitioners. Others may extend this requirement to include all providers, such as mid-levels, associated with the contract.
- Conversely, if the dental plan does not necessitate individual credentialing, the practice can bill under the clinic name for new providers. In these instances, most dental plans require an updated roster of providers delivering services under the agreement.
Dental Credentialing Billing Mistakes for Temporary or Substitute:
When a provider steps in for an absent colleague, the billing options turn more nuanced.
- Locum tenens arrangements, and
- Reciprocal billing arrangements.
Locum Tenens Arrangements
- A non-permanent solution for patient care. The professionals are ready to offer short-term support without the goal of permanent employment.
- Billed services under the absent NPI, accompanied by the modifier for each coding. Locum gets compensation on a fee-for-visit or per-diem basis.
- Medicare stipulates that when an on-staff doctor is unavailable, the bill for a substitute doctor, provided the on-staff doctor accepts the assignment.
- Additionally, a strict 60-day consecutive limit, starting from the first patient seen. Even short gaps due to vacations or days off count towards this limit. Once the 60 days are up, the urgent care clinic cannot bill for that locum. They need to engage a different locum.
Reciprocal Billing Arrangements
- A reciprocal billing arrangement is a flexible, informal agreement that allows practitioners to support each other during absences, ensuring continuity of care without formal documentation.
- Reciprocal billing is a powerful solution for urgent care facilities when locum tenens arrangements are not an option.
- Similarly, locum tenens, these reciprocal billing arrangements are effectively capped at 60 days.
- Additionally, Medicare requires credentialed doctors to ensure consistent, quality care.
Dental Credentialing Tips for Non-Credentialed Providers:
If locum tenens or reciprocal billing arrangements are not the practice billing needs. There are other effective strategies to bridge the gaps while the providers obtain their credentials.
Consider these operative ideas to enhance productivity:
- Familiarize yourself with the intricacies of the contracts and understand how to bill for non-credentialed providers under compliance.
- Allow non-credentialed providers to treat only self-pay patients, thus maintaining revenue while credentials are pending.
- Assign non-credentialed providers to perform procedures that do not require credentialing, efficiently utilizing their skills.
- If the insurers allow non-credentialed staff, maximize their schedules to alleviate workload until credentialing.
- Work with patients seeing a non-credentialed provider (out-of-network) to explore payment plans or alternative financial options.
- Begin the credentialing process immediately, ideally during the interview phase. That ensures the new providers are already in the system before hiring, speeding up the completion of their credentials.
Mistakes when Billing Non-Credentialed Providers:
Incorrect Data Feed: When an application lacks correct details, it becomes a prime target for delays and denials. Working with Capline Services, look for misspelled information, incorrect postal or email addresses, misentered identification or license numbers, and erroneous NPI numbers to avoid these issues.
Unbundling: It raises significant concerns for audit teams and potential fraud or misuse.
Duplicate billing: A provider files the same claim with different insurance companies or a technical glitch in the system.
Inadequate Documentation: Disorganized or poorly handled documents can lead to ambiguity and complications throughout the application process. It can lead to resubmission. Taking the time to organize and present supporting documents can make all the difference.
Insurance verification: Accurate insurance information before appointment scheduling is crucial to avoid billing issues, claim rejections, and delayed payments.
Incorrect coding: Relying on wrong or outdated codes can result in claim denials, impacting the cash flow.
