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Top 5 Reasons Your Dental Claims Aren’t Getting Paid

Are you looking to increase your dental practice cash flow? One area of business that heavily impacts monthly production is the dental insurance claim process. A very time-consuming, tedious process, dental claims may not be getting paid due to several reasons, but almost always begins with lack of follow up with the insurance companies after submission.

  1. The dental claim didn’t make it to the insurance company.

Many times, dental claims are submitted electronically and staff don’t check to see their rejections report or if an area of the claim is incorrect. The issue lies with the quality of the information.

  1. The dental claim is missing complete clinical documentation.

Insurance companies require a detailed clinical report and narrative depending on the procedure. The dental claim may be missing narratives or x-rays, and there isn’t enough documentation on clinical notes for reimbursement.

  1. The dental claim was submitted with bad information.

Sometimes it’s as simple as poor information from the patient or a mistake inputting information on the staff’s behalf (i.e. birth date, address, social security number, etc.) Always verify eligibility information before the patient sits in the chair.

  1. The dentist’s credentialing is out of date.

If the dentist’s credentialing is out of date, insurance companies hold onto the claim. Manage your renewal closely and start the credentialing update process at least three months ahead of time to ensure ample time for completion.

  1. The insurance payment has been completed, but hasn’t been posted.


Often, the claim has been submitted and payment from the insurance company has been sent, but a bottleneck is created at the posting phase. This happens when staff are too busy and the payment hasn’t been recorded in your software.

As we all know, dental billing management is a full-time job. Dental Support Essentials offers a turnkey Accounts Receivable solution for your practice from insurance eligibility checks, billing, follow up, appeals, and more! Trusting experts to manage your AR will save your staff valuable time and increase your reimbursement rate. So, what are you waiting for? I’d love to connect and discuss opportunities to streamline your dental practice!

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Top 5 Reasons to Outsource Dental Billing

Is your dental practice experiencing a low collections rate or low morale due to overworked staff? As the practice owner, you may recognize things need to change but feel stuck and don’t know where to begin. Don’t fret! An effective, non-invasive solution of outsourcing billing and insurance eligibility to experts can help your dental practice thrive with satisfied patients, content staff, and increased monthly production.

There are common signs to look out for that indicate your dental practice could benefit from outsourcing, including:

  1. When phone calls with insurance companies (to get a breakdown of a patient’s benefits) are taking up too much time from your dental staff. Lengthily phone calls can take away valuable time with patients and can negatively impact your business. If patient interactions are suffering, it’s time to outsource your eligibility so your front office staff can focus on what matters most.
  2. When the dental office manager says, she can’t get all her work done or refuses to take a lunch break and works overtime. This is a sign you need a second pair of eyes on your dental office’s books. The office manager is overworked and likely experiencing burnout, which increases the likelihood of her finding a new place of employment and leaving your dental practice in a bad spot. Outsourcing billing will allow your business operations freedom and not dependent on one person.
  3. When there is a big stack of EOBs that haven’t been posted or monthly production is taking longer than 30 days. There should always be less than a month’s production on the books for the said month. If it has been over 90 days old, you need to outsource.
  4. When your over-the-counter payments are not being collected by the front office staff because of competing demands (eligibility checking and billing). If these over-the-counter collections aren’t happening, it’s time to outsource.
  5. When you know you need a staffing change, but are afraid to act because your business hinges on your existing employees.


If your dental practice is experiencing any of these pain points, compare the financial impact of hiring an additional employee verse outsourcing. Hiring a billing manager requires a salary, benefits, employee management, etc. Outsourcing to experts such as Dental Support Solutions is paid on a percentage (3.5%) of monthly collections. If you have a slow month and collect less, you pay them less. It’s a smart, scalable solution to increase collections and decrease Accounts Receivable.

Outsourcing dental billing operations ensures that the practice can survive apart from any one employee and business can continue if an employee leaves. Outsourcing can remove fear and present you with another option. Don’t feel stuck! Dental Support Essentials works with dental practices to manage their eligibility and billing operations. Your Accounts Receivable will improve, productivity of your staff will increase and they’ll have more time to fill your schedule, since they won’t be bogged down by billing management.

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4 Keys to Help Protect Your Dental Practice

It used to be that dental offices existed as their own little island. The same five employees would stay for 20 years and personal and professional lines could become blurred. From dentists giving their employees loans to babysitting each other’s children, dental office staff interacted as an extended family unit. Dental office environments continually evolve and as technology advances, the landscape of employee and HR management needs to change. Time and time again, dentists don’t protect themselves or their practice until it’s too late and a former employee is wreaking havoc on operations.

Invest time upfront on simple procedures and documentation to ensure your dental practice has a trustworthy, accountable staff.

  1. Sign a non-disclosure and non-compete agreement

Create a non-disclosure for all employees, and non-compete agreement for dental associates and hygienists to review and sign. This agreement outlines that if the employee leaves the practice for any reason they (1) will not recruit patients, (2) will not tell patients why they are leaving the practice and (3) will not inform patients of their new employer. The sale of a dental practice is a common event for staff attrition to take place. With change in practice ownership, staff don’t always stay under the new dentist.

Hygienists and dental assistants take immense pride in building authentic, caring relationships with patients and often feel like they may have ownership over the relationship. Hygiene accounts for about 30 percent of a dental office’s business. Don’t allow your hygienists to reduce the selling value of your practice or impact your revenue if they leave on unhappy terms.


  1. Perform criminal background checks

Criminal background checks are a common hiring procedure across industries to give a comprehensive report of a candidate’s history and background. This ensures you’re hiring dependable, ethical staff members. Some dentists may feel criminal background checks are big deal or “over-the-top”, but you are ultimately protecting your practice and business.


I’ve worked with several dental practices that did not complete criminal background checks prior to hiring front office staff resulting in bad hiring decisions of former convicted felons. One red flag to be aware of is extreme gaps in employment history. This can sometimes indicate potential past criminal history. And remember, this isn’t a matter of a lack in trust, but having a low-cost solution to making smarter hiring decisions and protecting your patients, staff, and practice.


  1. Document all employees have received (and agree) to the dental office employee manual

A dental office employee manual outlines procedures and expectations for each employee of a dental office including, standard conduct, dress code, HIPAA and OSHA compliance, etc. To ensure compliance, each employee should receive a copy of the employee manual and provide a signature that they have received it. Documenting the rules and employee’s signatures of agreement will help with employee and HR relations if situations arise.

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Keeping Your Patients Safe: Proper Dental Practice Infection Control Procedures

Proper infection control is a top priority of any dental practice to ensure the health of a patient is not compromised and to prevent the spread of disease and germs. Each dental practice must meet compliance and standards outlined by their state dental board. Achieving infection control is just the tip of the iceberg – it’s imperative to keep accurate and timely documentation of your dental office’s infection control policy and manual, staff training log, equipment and tool sterilization reports, etc.

Aside from maintaining the health of your patients and staff, having proper infection control protocol can safeguard your practice against retaliation. What kind of retaliation you may be asking? Disgruntled former employees. Time and time again, I’ve worked with clients who have experienced huge headaches because terminated employees alerted their respective state dental boards and made a claim on their former employer (insurance fraud, improper infection control procedures, etc.). State dental boards must investigate each claim they receive. Following a thorough weekly checklist of infection control activities can help keep your dental office up to date and ready for inspection at all times .

Infection Control Policies and Procedures Check List

  • Have a detailed infection control policy and manual for your dental practice printed and available for all staff members.
  • Keep a detailed training log that outlines each training, certification (i.e. CPR) staff member name and title, and their signatures confirming completion.
  • Keep a weekly log to record and stay consistent with sterilization testing of your dental equipment each week.
  • Some state dental boards provide an infection control manual. Obtain a copy online and use this manual as a guide to ensure compliance.
  • Plastic materials (i.e. x-ray holders) used to be the standard, but now tools must be autoclavable.
  • Never re-use disposable products. In attempt to save money, offices think they can wipe or spray these kinds of products for a second use.
  • Keep dental instruments in their sterilized bag up until they will be used on the patient. Reducing outside exposure will ensure proper infection control.
  • Always cover instruments, tools, and materials that may not be in use (i.e. containers for cotton balls). Aerosols can travel and stick to surfaces farther than expected.
  • Spend extra time wiping down every surface every time a patient is seen.
  • Keep your office’s ‘permissible practices document’ up to date. This document outlines all of responsibilities and tasks administered by each dental staff member.
  • Be sure to properly dispose of needles and biohazards, and keep documentation of removal.
  • Film x-rays are lined with lead – be sure to properly dispose of the lead foil. Additionally, save amalgam fillings for scrap metal.

Proper infection control management requires thorough documentation of your office’s day-to-day processes. Though infection control is expensive (I estimated it to cost $25/patient twenty years ago), it’s necessary for the health of patients, staff, and a well-run dental practice. Also remember, you don’t have to let the inspector in your office if they arrive unannounced. You can ask them to come back when the time is convenient for you.

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How to Leverage the Top 3 Underutilized Dental Practice Resources

One of the most common themes I encounter when evaluating a dental practice’s existing billing, scheduling, and management operations is the misconception that hiring additional staff or purchasing new technology is the go-to solution for solving areas that need improvement. When really the answer almost always lies in leveraging the resources you already have at your disposal to increase productivity, optimize schedules, and even grow monthly profit.

  1. Utilize the internet and insurance carrier web portals for eligibility checking.

Many insurance carriers have comprehensive online portals and websites available to check patients’ eligibility and obtain digital (PDF) reports that can be saved directly into a patient’s file. It’s common for front office staff to check eligibility over the phone, which is extremely time consuming and often very frustrating. Consistent negative feedback I hear from the front desk staff is the heavy workload due to the volume of insurance calls added to their other tasks. Using online portals and websites won’t fully replace calling insurance companies, but it will drastically reduce the time required and make this important task manageable. With less time being spent on eligibility checking, there will be less burnout and happier long-term employees.

  1. Maximize the existing employees your dental practice has on staff.

Dental offices often hire advanced qualified personnel (AQP) to help dentists provide care that a dental assistant or hygienist cannot. This hiring strategy when employed properly can allow the dentist to care for more patients.

I recently worked with a dental practice that had an AQP on staff, but was only being utilized at the skill level of a dental assistant. Instead of the dentist seeing 1.5 patients each hour (if the AQP was being utilized properly), the dentist was only seeing one patient an hour. The dentist was open four days a week and fully booked far in advance. Instead of needing to have an extra office day or extend hours, properly using the AQP to complete appointments would increase patient flow. Sometimes dentists are new to working with an AQP and have a tough time giving control over to someone else to finish his/her work. Since AQPs have a higher paygrade than dental assistants, it’s important to effectively schedule their time in harmony with the doctor.

  1. Learn every feature of your practice management software.

Staff Scheduling – Almost all software has a coding feature to easily visualize the staffing calendar to optimize appointment slots. For example, assigning colors to each personnel (doctor, AQP, dental assistant, etc.) can help the staff or office manager see the time requirement for each staff member against each appointment.

Appointment Setting – Utilizing the cancellation or broken appointment list feature can help in easier patient follow up and communication, and fill more open dental chairs when a cancellation occurs. For example, if a patient cancelled an appointment two weeks ago and it was recoded properly, and a last-minute opening occurs in the dentist’s schedule today, you can easily contact the patient to see if they can accommodate the opening. The patient will feel valued and top-of-mind, and the doctor can maximize his clinical time. Additionally, dental practices often invest in appointment confirmation services, like an email or SMS service. Instead of recording the responses from the service and then following up with patients to confirm via phone, I’ve seen front desk staff complete these tasks simultaneously, doubling up on their communication. If your practice pays for this type of service, fully utilize it – don’t pay for it twice (monthly subscription + staff hours)!

Treatment Plan Management – Many software systems can link treatment plans to an appointment for easier management and better results in the practice’s overhead. For example, a patient’s treatment plan could recommend work across three different appointments. One is scheduled the day-of the treatment plan review, but two are still open. As weeks or months pass by, you can run a report to show incomplete treatment plans, and allow for easier follow-up with patients. It’s important to always link a treatment plan to an appointment and add details (dollar amount, type of work, etc.) This will allow your practice to understand the projected monthly and annual income.

Prioritizing continuing education beyond your clinical staff is extremely important so your practice operations can run efficiently, saving time and money. Each client I work with always begins with reviewing overhead and finding areas that can be improved. Outsourcing time-consuming activities, like billing and eligibility, to experts can redirect practice staff time to focus on what matters most – excellent patient care. Dental Support Essentials offers ongoing support services including staff training, practice management services, credentialing, billing, and eligibility.

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Strategies for Forecasting Revenue

Twelve months, 52 weeks, 365 days. A calendar year offers endless opportunities to deliver excellent personalized dental care to individuals, families, and communities. As we all know, life happens, schedules change, vacations and holiday breaks occur, and dental care may not be top of mind for patients. There are two months – September and February – that traditionally experience a dip in appointment volume. Patients are going back to school in the fall and winter weather can keep patients from making their appointments. A dip in appointment volume can affect your practice’s average monthly production, but don’t fear – there are smart strategies you can implement to prepare for these traditional slow performing months so you have a level average monthly income.

Increase Appointment Availability During High Volume Months

In comparison, the most popular months for dental services are August (pre-back to school), December (holiday break), and January (the time to maximize dental benefits and HSA/FSAs). The best strategy I’ve implemented and have seen succeed across practices to offset the slow months is to increase appointment availability during the high-volume months. It may seem a bit counter intuitive to increase an already high patient influx, but the key is to maximize these popular times for the patient.

Offering additional hours or opening your practice on a Saturday will show your patients you care and will build goodwill. Showing patients, you are considering their needs and schedules, and offering them a thoughtful solution will set your dental practice apart. You are a part of the patient’s community – a trusted healthcare giver that plays a vital role, likely over different life stages and years.

Practical tactics you can implement to aid your dental practice see more patients during these busy months are:

  • Use a dental staffing agency to hire one or two extra temporary hygienists. This will allow you to see more patients during your normal office hours. Make sure to plan and book extra staffing at least six months in advance of the winter holidays.
  • Extend your office hours – an hour or two earlier or later than usual – to accommodate patient’s schedules.
  • Consider opening your practice on a Saturday for half of the day. Patients will appreciate the weekend availability, since the work week may be difficult to schedule around other commitments.
  • Specifically target school-aged families through direct mail (i.e. post cards) or emailers to inform them of your extra appointment offerings. Look up the holiday schedule of the local schools online to help advise which days you should market.
  • Try to book teeth cleaning appointments in early August or December, so there is enough time to schedule any additional work later in the month.
  • Increase promotion of custom fit mouth guards during the month of August for the school year’s sports. All athletes – football, basketball, baseball, softball, hockey, wrestling etc. benefit from well-fitted mouth guards. It’s smart to offer these at an affordable price, since patients could opt for a cheaper, not as well-made mouth guard from general sporting goods stores.

Maximizing your practice’s busiest months will ultimately bring your patients increased satisfaction and goodwill. In addition to happier patients, your annual production forecast will be more accurate, since you adjusted to cover the slower months. It’s also very important to not spend the increased money your practice made during these high-volume months. This cash flow is to cover the slow months, it’s not the time to buy new equipment or remodel the front office. A bit of planning, extra staffing, and marketing can go a long way in making a meaningful impact with your patients and your practice have an accurate and dependable annual income.

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Dental Provider Credentialing 101: Medicaid Management

Over the past few weeks, I’ve detailed the ins-and-outs of the dental provider credentialing process – a painstaking, time intensive, detailed, and necessary procedure for the modern 21st century dentist to stay competitive and offer dental care to an expanded in-demand patient base.

There is a niche subset of dental care that requires even more scrutiny and exhaustive efforts to complete credentialing. Medicaid, which is managed by each individual state, requires additional manpower, maintenance, and vigilance for effective dental credentialing. Because of the momentous effort required behind providing Medicaid dental care, it’s recommended for clinics with larger infrastructures and not the solo practitioner. You must work twice as hard to get paid half as much than the traditional in-network or out-of-network dental patients.

Medicaid Dental Provider Credentialing

  • Medicaid credentialing requires a double application process – first complete the traditional dental credentialing application with the state, then get credentialed with one or more Managed Care providers (i.e. DentaQuest, United Concordia, etc.).
  • Medicaid can be different in every state, so you’ll be registering with the individual Medicaid state program.
  • You’ll need an individual Medicaid provider number, as well as a provider number for your practice.
  • Remember to plan accordingly, as the Medicaid credentialing application always takes longer than prescribed. Many states say they will approve applications within 90 days, which often doesn’t happen and delays the payment process and affects the practice’s bottom line.

Medicaid provider companies are notoriously understaffed, which results in slower processing time. These companies have also increased automation and electronic processing. When it works, it works well, but if there is a problem, it’s a nightmare to fix since it’s more difficult to get a person on the line to help.

A Medicaid Dental Case Study: The Devil Is in The Details

As mentioned several times throughout this dental credentialing series, closely managing the details is imperative to the financial health of your practice. I recently helped a dentist, who provided Medicaid services, dig out of financial distress and suspected fraud, all due to a single application error.

This dentist was seeing patients using four different Medicaid carriers and PPO plans, and quickly realized her pay was significantly lower than it should be based on her high volume of patients. My first instinct was there may be a claims submission issue, so I resubmitted the claims, but each got denied because they were previously paid. But there was one big problem with this finding – no checks were received by the doctor. After a few calls and emails, I discovered these checks were being mailed to an address that didn’t exist. How could this happen? Someone manually entered the wrong address number on the credentialing application. One simple initial error had a disaster domino effect and negative impact on an entire dental practice and quality of life of a dentist.

Medicaid is a unique system, and since there is no central governing body, each state and provider is different. In this case, the missing checks caused me grave concern because we didn’t know if they were being cashed, which raised a huge red flag of potential fraud. With the risk of fraud present, I escalated this case immediately to Medicaid provider executives, yet it was received with no sense of urgency. It took me months to correct this error after several meetings and dead ends. Because of this one error and ensuing arduous process, the dentist was unable to make money and ultimately ended up leaving Medicaid dentistry.

The biggest takeaways about Medicaid dentistry and credentialing is the amount of manpower and vigilance that is required to see success. It takes dedicated resources and time to manage these minute details, carefully record the status of each application, and diligently communicate with the credentialing companies. Carefully evaluate your existing internal resources and patient demand to understand if you have the necessary manpower available to manage a Medicaid practice.

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Dental Provider Credentialing 101: Common Application Mistakes to Avoid

As discussed in part one and two of my dental providing credentialing blog series, it’s important to fully understand the implications of providing in-network vs. out-of-network care, allow ample time for the application process and take a detailed, thorough approach with the insurance companies during the inquiry process to negotiate the best fees schedules.

Now that you have a strong foundational knowledge base of the dental provider credentialing process, it’s time to address common application mistakes, so your credentialing can be completed in a timely manner and patients can be seen sooner.

  1. Be sure to complete each application response, even if the question doesn’t apply to your practice (i.e. enter in N/A). If a response is left blank, the insurance companies often consider it an incomplete application.
  2. Ensure your malpractice insurance is current and up to date during the credentialing approval process. The approval process can often take up to 90 days, so contact your malpractice insurance provider and extend the policy if it is set to expire during this timeframe.
  3. Always include detailed supporting documentation that outlines the changes in the practice (full details below).
  4. Plan and allow ample time (~3-6 months) for the approval of your dental credentialing. Credentialing is not a quick process, which is often the biggest headache experienced by dentists, since approval can deeply affect which patients can be seen (in-network vs. out-of-network).
    • Ensure all forms (W-9 and attestation page) and signatures are up to date and as recent to the application submission date as possible. The application process could be delayed if your forms are too out of date (i.e. you might start getting credentialed with the big companies first, and wait 3-6 months until targeting and applying for the smaller ones. Even though the forms have been completed and collected already, since considerable time has passed, you need to make sure the dates are near the new submission date.)

The Importance of Supporting Documentation for the Dental Credentialing Application

Providing detailed supporting documentation is instrumental to the timely approval of a dental credentialing application. Specifically, a detailed letter on the dental practice’s letterhead should clearly articulate the details of the changes. I find it best to display this information in a table format with big, bold headings. Details to include in the supporting documentation are:

  • New doctor’s name, tax ID and license numbers.
  • What doctor(s) are staying at the existing practice, leaving the practice, their identifiers, and the effective date the change will take place.
  • If you’re changing locations or working at multiple locations, be sure to clearly detail and label the locations. You don’t want your new credentialing to cancel out your old credentialing, which can happen due to confusion on behalf of the insurance company. This is as simple as providing the new doctor’s tax ID number and adding it to the old practice as a new location.

Dental Credentialing Management Tips

Implementing a sound credentialing management and tracking process will help your practice stay on top of communications and status updates with the insurance companies.

  • Confirm the application was received by the insurance company. Follow up in a consistent, friendly manner until you have confirmation from the insurance representatives. Outreach over email is best so you have a written record of communications.
  • Follow up with the insurance companies on a weekly basis.
  • Keep a detailed spreadsheet that records the status of each application including, insurance company name, contact information, call log, and detailed notes.
  • Utilize an online calendar app to keep track of reminders for follow up calls, emails, etc.
  • Be professionally obnoxious and stay diligent in follow up, until you’ve received a response and confirmation of your credentialing application. If you do not receive a response, it often means they did not receive it!

Working with several practices over the years, I understand how painful the credentialing process can be with insurance companies. It’s a timely, detailed process that requires nonstop management and diligent follow up. Though the credentialing process is a bottleneck in dental practice management, it’s a necessary process for practices and doctors because so many people rely on their dental insurance to afford the dental care they need.

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Dental Provider Credentialing 101: Application Process & Insurance Inquiries

Last week, I gave a full rundown of dental provider credentialing basics and outlined initial steps to get you started and make a confident decision to provide in-network or out-of-network patient care.

There are often two categories aligned with the dental credentialing process when establishing or joining a dental practice – (1) you may already be an in-network provider from a previous dental office or (2) you’re beginning the process from scratch. If you’re already an in-network provider, find out who you’re in-network with and the process is simple – it’s a matter of updating your practice’s address and new tax ID number, usually by completing an update form specific to each provider.

If you’re starting from scratch with the dental credentialing process, completion of a full application is necessary. Several states have a universal dental credentialing application using CAQH ProView, which requires an in-depth look at several documents. A full list of documents and identifiers for submission include:

  • National Provider Identification (NPI) number – An NPI number can be applied for online and is cost-free.
  • Dental license for the state you practice in.
  • Proof of malpractice insurance – Submit the page of the policy that outlines the length of time and amount of coverage you have.
  • DEA certificate – This is received from the federal government to prescribe medication. It’s important to password protect this document.
  • Certificate or diploma for a specialized degree – If you’re a specialist (i.e. orthodontics) you will need to provide proof of completing the specialization.
  • Additional board certifications (i.e. pediatric board certified).
  • W-9 form – This documentation reports your income to the federal government and could be different per dental practice you are employed by. You might need more than one W-9; it needs to belong to whoever is receiving the check.
  • Professional references – The CAQH application requires professional references (i.e. colleagues), but often are not actually contacted for application approval.

The best place to start and guide your application is your professional resume and personal information records (SSN, date of birth, etc.). Once you’ve completed and submitted your application, you’re ready to start reaching out to the dental insurance companies and begin making inquiries.

A RoadMap for Dental Credentialing Inquiries with Insurance Companies

  1. Visit the insurance company’s website. There is a section specifically for providers (i.e. ‘join our network’), which is where you’ll submit the initial credentialing inquiry.
    • Helpful tip: It’s smart to create a generical email address just for credentialing to help manage the credentialing process and documentation management.
  2. After the initial inquiry, the insurance company will send you a contract to review and sign (but often with no fee schedule).
  3. Ask the insurance company for their fees schedule, as well as their electronic funds transfer paper work to begin the process of account setup (you’ll need a voided check).
  4. After reviewing the insurance fees schedule, it’s time to negotiate. Insurance companies never offer their best rates up front, but will usually negotiate up to 20 codes. If you’re a specialist or live an underserved area, you will often have more leverage to negotiate.
  5. Pay attention to your most commonly billed codes (i.e. exam, filling, including amalgam, crown codes, and denture codes) and negotiate higher fees for these more highly used codes. Insurance companies will go back in forth no more than 2-3 times to settle on a fees schedule.
  6. Be sure to review and negotiate downgrade clause codes. Dental insurance companies often have fee loopholes around downgrade coverage. For example, a white filling is performed on a patient and the insurance has 80% coverage for white fillings, but the said fee policy has a downgrade clause attached (which can be buried in documentation), and the insurance company pays 80% coverage for only silver fillings. The patient will not receive the expected coverage due to this downgrade clause.
  7. Always set up direct contracts with companies that negotiate. If you do set up a direct contract, always make sure to opt out of the third-party fee schedule, so the insurance company uses the higher fees schedule (which is typically lower when a third-party firm is involved).
  8. Consider working with a third-party credentialing firm to assist with fee negotiation and management. Third-party firms can often help negotiate higher fees, but will likely only contract the work if you agree to an added paid service (i.e. using their claim service, etc.)

One of the top reasons I’ve seen for frustration and burnout among dentists is the exhaustive amount of time that can be required for credentialing and fees schedule setup and management. Dentists often reach a point to make the decision to join a corporate dental practice or engage outside dental practice management expertise if they want to maintain their sole practice. What has your experience been with dental provider credentialing?

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Dental Provider Credentialing 101: Part I

As dentists start their career and establish, join, or take over a dental practice, there is always an elephant in the room that needs to be addressed and decided upon: to be credentialed or not to be credentialed?

To answer that question, let’s define the basics of dental credentialing – what it is, why dentists decide to get credentialed, and the initial steps on how to begin the dental credentialing process.

What is Dental Provider Credentialing?

Dental credentialing is the process of a dentist entering into a contract with an insurance carrier. The doctor then becomes a provider of that insurance carrier and gains access to a larger patient base, therefore increased business opportunities. Insurance carriers have a very thorough, in-depth vetting process for dentists to become credentialed including providing proof of dental degree and dental license, malpractice insurance, law compliance, Americans with Disabilities Act compatibility, etc.

The Dental Insurance Carrier Contract

It’s important to thoroughly and carefully read through the insurance carrier contract ahead of signing it. The contract outlines the plan the dentist is participating in, fee schedules, and what the dentist can and cannot charge the patient. It’s common for dentists to sign the contract document without fully understanding all of the contractual obligations. For example, signing the contract often gives the dental insurance carrier permission to audit the dental practice and documentation. Additionally, insurance carriers can determine if certain procedures are billable or not. Often, insurance companies will not allow dentists to bill the patient for a procedure (i.e. crown buildup) that would normally be billed if the dentist was out-of-network.

In-Network vs. Out-of-Network

The majority of dentists today belong to at least one insurance carrier network. More and more patients rely on their dental insurance for affordable dental care and are co-pay sensitive. Often the question “what does my insurance pay?”, is the driver for completed appointments and treatment plans. Alternatively, dentists can choose to work outside of insurance networks (out-of-network) resulting in more direct payments and less insurance management, but there is a good chance the patient pool will be significantly smaller. Out-of-network patients will generally pay higher out-of-pocket rates and fees.

Dental credentialing is also on an individual basis, so if multiple doctors reside under one practice, each can choose to decide if they want to be in-network or out-of-network and what plans they accept. Each dentist will have to be credentialed individually with each insurance provider. One application cannot be completed for the whole practice if multiple dentists wanted to fall under the same insurance carrier.

Where to Start with Dental Credentialing

  1. Research and understand the top large employers in your city and county (i.e. hospital and school systems) and which insurance carriers they employ. Joining the insurance carrier that local major businesses use will put your dental practice among a large in demand customer base.
  1. Review the insurance carrier fee schedules. Sometimes these fee schedules don’t have a fair payout (i.e. Medicaid fee schedules) and end up costing the dental practice more. You have to ask yourself if it’s worth being a part of said network. Don’t sign or turn in a contract without reviewing a fee schedule. Many times, I’ve had to ask more than once to review the fees.
  1. Understand your competition and what the demand is for different insurance carriers. The front office staff can start by making a list of the insurance plan patients ask to participate in and calling around to other local dental practices. Choosing what insurance carrier to join can be tedious, so you’ll want to be selective and negotiate fees.
  1. If you’re buying a dental practice, you’ll likely choose the insurance carriers that the former dentist participated in to include existing patients. It’s important to talk to the front desk staff for intel on existing plans to determine any changes or adjustments.
  1. Are you already a credentialed dentist? If you have been working in a dental practice prior to buying or starting a new practice, you may need to only to fill out an update form for the insurance company. As stated before, the contracts are with the individual providers so your contract (not necessarily the fee schedule) can be linked to more than one location. Find out from the office manager of your current practice which companies you are currently participating with and contact them to get provider update information.

Itching to know more about the ins-and-outs of dental provider credentialing? Over the next few weeks, I’ll continue to break down the details and nuances of dental credentialing and provide tips and tricks, so each dentist can make a confident decision.