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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.

1 thought on “Dental Provider Credentialing 101: Medicaid Management

  1. It’s good to know that Medicaid is different in every state so that I can make sure that I know the rules for the state I’m moving to. I’m actually moving pretty soon so I’ve been looking for a new dentist. I’ll make sure to look at the policies for that area.

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