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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.