The Do’s and Don’ts of Dental Credentialing

Provider credentialing and enrollment is a primary necessity for running a successful dental practice. Credentialing enables the provider to get empanelled on the network of various commercial and government insurance companies. That aids immensely the provider to maintain a steady patient flow through referrals and hence, more revenue is generated for the dental office, the core necessity of any business .

Credentialing is relatively straightforward as a process. Here, information about a dentist/provider’s qualifications like education, certifications, work history, licensure, and so on are shared with a payer for review and verification. After clearing this thorough and rigorous vetting process, the provider gets confirmed by the payer and starts getting reimbursements for the services rendered by him or her.

Looks like a simple process, right?
In reality, executing a reliable and consistent credentialing process is not always that simple. Over the years, Capline Services has worked with a large number of dental offices and independent practices for their credentialing and enrollment needs. That enabled us to have amassed a great pool of knowledge on the subject. Using that knowledge, in this article we have tried to highlight certain Do’s and Don’ts of credentialing that people working in the industry should adhere to.

First we go with Do’s

• Adhere to the details: Credentialing is a vetting process thus, there should be pristine level of attention given to detail checking. Application errors often result in delays and potential denials. A typical credentialing application will ask for address of practice, phone and other contact information, copies of licensure, services provided, employment history, peers references, average patient profile and all records of past legal troubles regarding practice if any. Any mistake in providing or procuring any of this data may delay provider credentialing, and can also become ground for a denial.

To avoid this, all provider applications should go through an intense audit process to certify accuracy before being submitted to the committee. Getting it right the first time leads to faster credentialing. After the provider has completed the application for the credentialing process, then time should be taken to verify the information they’ve provided. This can be done by taking the provider’s self-reporting information and juxtaposing it against primary or originating sources.

Here’s a look at some of the key elements that should be verified along with the correct primary source that could be used to verify that information.

Provider Education – Sources: American Medical Association or Medical School

• Board Certifications – Source: American Board of Medical Specialties
• Medical License – Sources: State Medical Board or Department of Health
• NPI – Source: National Plan & Provider Enumeration System
• Sanctions – State Sources: Medicaid sanction list in provider’s state of practice

Federal Sources: System for Award Management and Office of Inspector General

• DEA Registration – Source: National Technical Information Service
• Board Certifications – Source: American Board of Medical Specialties

Ensure office is adequately staffed: Credentialing being a labor intensive process calls for no compromise on staffing. People are needed to manage the process, maintain data, fact check the reporting etc. Any misses on having the appropriate allocation of staff can lead to increased mistakes which slows the whole process down. Credentialing as a process needs a lot of detail checking and requires specialization at some points from the staff. To do any cost cutting on staff might jeopardize the whole process.

Thus, segregate the credentialing process into different jobs and hire specialized people to perform those jobs. Also, there should be proper training channels for employees/staff to hone their skills to perform the job better.

Now, let’s talk about the Don’ts

• Don’t delay in sending applications for review: Once the application forms have been thoroughly gone through, they must be sent for review without delay. Thing to be kept in mind is, there’s usually more to credentialing than just sending in forms and then waiting for approval. Further any questions raised or any additional information requested should be promptly answered or otherwise there might be rejection.

Communication is Essential – Working on establishing a rapport with the representative of the insurance company dealing with your case may make things easy. Procuring that individual’s contact information and communicate regularly to make sure that all questions are answered and follow up has been done on applications that are in processing.

Don’t delay in starting: Many practices get started too late, which can be a matter of success and failure for the practice. At a minimum you would want to give yourself at least 90 days. Realize that you are working on someone else’s timeline – the payer. The responsiveness of the payer to your application will be determined by their workload and their motivation to add new providers to their network. As payers have merged and supersized, a practice's ability to expedite an application has shrunk.

Capline Dental Services in now offering Dental Credentialing in Florida as well. for more information please visit: Florida Dental Credentialing