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Melanie Miller-Aranda
Co-Owner, ICS
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Credentialing or Re-Credentialing & Negotiations: Feeding Your Practice!
By Melanie Miller-Aranda, Insurance Credentialing Specialist

Across the nation there are associate dentists entering into existing practices and dentists purchasing their own practice or fee-for-service office who are interested in becoming dental plan providers. Do you find yourself in one of these situations? Some common questions that come up in these scenarios include: Who do I contact? Where do I start? How do I choose?

It is important to know that all dentists who have associates need to credential them individually. Credentialing is based on the Tax Identification Number (TIN/EIN), the physical office address, and the dentist’s license. If any one of these three things changes, you are no longer considered an in-network provider with most plans. This also applies to dentists who are credentialed elsewhere. Keep in mind, it is imperative that you indicate the treating dentist’s name on all claim forms. Most dentists are honest, ethical professionals who are unknowingly putting themselves at risk of committing insurance fraud by not disclosing the treating dentist on the claim form in order to retrieve in-network benefits. The up side of this is when you credential your associate, their name will as well be listed in the provider directories - giving you and your associate the opportunity for more exposure to obtain new patients for each plan.

If you are a dentist who has purchased a new office, the same protocol applies. You cannot utilize the previous owners’ information for the benefit of an in-network status of the plans. Nor can you utilize your credentials from any previous office you may have worked. Timing is everything with credentialing and negotiations. There are trigger points to retrieving a higher fee schedule with some plans according to the signed contracted date or previous participation. The best case scenario is to be an in-network provider of the plans of your choice and have patients the very day you open for business.

There was something to be said about patient loyalty in the past, and it seems that those times have somewhat passed. It has often been demonstrated that fee-for-service offices that have never been in-network providers have lost up to 30% of their revenue. With more and more Americans becoming insured medically, dental insurance is being offered along with medical insurance and patients are utilizing the benefits. Patients will often leave an office when seeking the benefit of an in-network provider, saving their family hundreds of dollars a year. If this is the case in your office, it may be time to consider participation with dental plans. Of course, you will need to make this decision based on your own preference.

Re-credentialing is required by most dental plans every one to three years, or upon expiration of documents (i.e. Malpractice, etc.). Maintaining your re-credentialing is just as important as your initial credentialing. All dental plans have their own protocol for re-credentialing requirements and they are very time sensitive. Unfortunately, in some cases dentists never even see the requested document as it may appear to be trash or junk mail to your staff. It is always advised for you to open all mail from the dental plans prior to discarding. What generally happens is the deadline for submission has passed and you the provider are no longer in-network. This is now a problem not only for you but for your patients who thought you were in-network and now you are not. Not only are you going to have upset patients, you will have wasted staff time trying to contact the plans to find out what exactly has happened and how it can be corrected. You could also lose your fee schedule and have to start all over. Value your time and your staff’s time by being proactive and complying with the re-credentialing requests. 

It’s so important to understand the plans and credentialing in the manner that best benefits you and your practice, as I’m sure this is your ultimate goal. Ensuring that you are receiving the best possible fee schedules with all of your plans, as well as maintaining your credentials, is imperative to keep your status active with the plans of your choice once you are credentialed.

These are just a few pointers about credentialing or re-credentialing & negotiations that will help feed your practice.

Melanie Miller-Aranda is the Co-Owner of Insurance Credentialing Specialist. Her experience working in the dental field since 2000 has given her insight to provide a credentialing service to the dental community.

Melanie can be reached via email at contact@insurancecredentialing.com

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