Whether you are part of a large dental group, a dental service organization (DSO), or a dental enterprise, there is one thing that is constant credentialing.
What is dental credentialing?
Dental credentialing is a critical step in the enrollment process when contracting with insurance plans. Providers are required to submit critical data and information to the plans to verify the validity of a respective provider’s’ credentials.
Why is credentialing important?
Dental credentialing provides benefits such as maximized revenue, lower denials of claims, and increased cash flow to the practice. It also allows dentists to become “in-network” providers—a status that brings yet another set of benefits, including less out-of-pocket expense for patients.
However, insurance carriers have a very comprehensive screening process for dentists to become credentialed. This typically includes:
• Demographic information
• Proof of dental degree and dental license
• Current and/or prior work history
• Hospital affiliations (if applicable)
• Liability insurance
• Board certification
Follow these best practices for documentation:
1. Create an onboarding packet checklist
2. Integrate the onboarding checklist into the human resources new hire process
3. Create a tracking log of missing information
4. Identify the documentation necessary to begin credentialing a dental provider
Timely and proper credentialing is essential
Because all dentists require credentialing—even those beginning work immediately following completion of dental school—the timing of credentialing is crucial.
In addition, failure for active dental providers to recredential in a timely manner may result in loss of reimbursement revenue due to deactivation. Deactivation of a provider may impact timely scheduling of patient visits due to a provider no longer being in-network with a respective plan.
In-network vs. Out-of-network
When properly credentialed, most dentists choose to be in-network providers for many reasons, including working with Health Maintenance Organizations (HMO). As part of an in-network plan providers can expect:
• Patient referrals from the insurance plan
• A contracted fee schedule—meaning “predictable fees” for services
• Reimbursement for services that may not be covered for out-of-network providers
• Lower out-of-pocket costs for patients
• HMO plans providing patients with increased offerings, with lower out-of-pocket contributions
• HMO plans producing recurring revenue through monthly “per-member-per month” payments
ADA/CAQH credentialing maintenance
American Dental Association (ADA) and Council for Affordable Quality Healthcare (CAQH) provide easy-to-use tools to maintain your credentialing. CAQH, a non-profit alliance, is the leader in creating shared initiatives to streamline the business of healthcare.
Best practices include:
1. Make a CAQH review and update for all new providers as an onboarding checklist item,
2. Track essential items that expire, such as your medical license, DEA numbers, board certifications, etc.
3. Set up a quality audit prior to application submission, ensuring that CAQH is re-attested every 90-120 days, and
4. Create a follow up protocol for open applications and auditing of all plans to ensure all providers are linked to the correct products and locations
The work of proper credentialing takes organization and maintenance, but it’s well worth the effort.
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