Dental credentialing acts as a line of defense for patients by insurers to protect them, ensure they get the best care, and ensure everything happens in compliance. The process verifies the practitioner's qualifications, education, licenses, training experience, and accreditations to check if the practitioner can offer services to patients.
The dental industry has a lot of challenges, and one of them is how to bill non-credentialed providers to have accurate claims. Credentialing is a necessary process with no room for regulatory errors to avoid fines and audits.
The dental credentialing vetting process happens before hiring dental professionals so the patients receive good treatment. The professionals can have a network of payers helping the practice. The challenge is treating providers who recently joined the practice, are convinced to submit claims during the credentialing process, resulting in delayed payments, dissatisfied patients, claim denials, and lost revenue. Let's dive deeper into how to submit legitimate claims that guarantee reimbursements while going through the lengthy process.
Claim submission requires the correct listing of the treating provider on the 2019 ADA dental claim form, irrespective of the network, for quicker payments. Credentialing is mandatory, but if a treating provider opts not to get credentialed, the claim is out of-network, which creates reimbursement issues as many plans do not offer out-of-network benefits. That creates collection issues between the patient and the practice due to negligence in assigning benefits, which generates settlement disputes and negative patient experiences. These unexpected complications can significantly damage the practice's reputation. If this feeling is unsettling, connecting with a reliable dental billing company like Capline Dental Services can support the practice with knowledge and effective management.
Inaccurate provider billing is costly, and the practice must vigilantly review the payer contracts, especially when dealing with non-credential dental providers.
The risk of improper billing can lead to criminal liability, and if the dental plan does not specify non-credentialed providers, the practice must refrain from using that provider's services.
Engaging a non-credentialed provider or a credentialed substitute accounts for the violation of the contract, irrespective of whether the contract is under the practice's name. It is vital to recognize that some insurance plans strictly require credentialing for individual practitioners, while others may extend this requirement to include all providers linked to the contract. Several dental plans accept non-credentialed providers. The new providers can bill under the clinic name with an updated roster of providers delivering services under the agreement.
Here is another situation when a dental provider is unavailable or temporarily replaced due to illness, pregnancy, vacation, or other reasons. The controlled billing process presents the following options to consider:
A locum is an independent contractor with permission to practice and bill for 60 days. Any short breaks, such as vacations or days off, will count against this limit. Once the 60 days expire, the locum is prohibited from billing and must engage a new locum. It is a temporary solution with no care for the long-term.
To bill locum under the absent NPI, including the correct modifiers(Q6) for each code. The compensation is a per diem allowance or fee-for-visit. Each service provided by the locum gets recorded along with the local UPIN.
For Medicare, the unavailability of an on-staff doctor proceeds with the billing for a substitute doctor as long as the on-staff doctor accepts the assignment.
The regular doctor can submit the claim and receive reimbursement for the services provided by the temporary replacement. The flexibility helps support each other during need while the patient obtains care without interruption. It is informal, without formal documentation, and accompanied by the Q5 modifier.
The absent doctor compensates the covering doctor by a reciprocal arrangement when a locum arrangement is not an option. Coverage periods for reciprocal arrangements can extend up to 60 days under specific criteria set by Medicare. A classic example of a reciprocal arrangement is a doctor stepping in to cover for an absentee doctor who is on-call for the weekend to ensure consistent patient care.
The billing needs are tricky, and if reciprocal and locum billing arrangements are not what the practice needs, below are several options to fill the opening, and the provider obtains the necessary credentials.
There is always a risk associated with non-credentialed providers. Therefore, a proactive approach can prevent mistakes such as duplicate billing, inadequate documentation, incorrect coding, unbundling, and incorrect data entry.
Treating patients without proper credentialing can cause serious challenges to the doctor's reputation. Thus, by identifying the issues and implementing strategic techniques during non-credentialed times, the providers can sail in these times without making trouble in their careers. Outsourcing to Capline with dental credentialing services safeguards administrative and financial concerns that ensure the primary focus remains on delivering patient care.
