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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. 

If a dentist does not successfully compete the credentialing process in a timely fashion, insurance reimbursement may be reduced, and the patient may bear the brunt of the payment by incurring increased out-of-pocket costs.

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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Bernard Kindell

Director, Credential Services