Looking Beyond the Coverage
Did you know that to participate in insurance group plans, you the dentist must be “credentialed”? Credentialing is a contract between a dental plan and the individual dentist who agrees to comply with the terms of the agreement and accept the fee schedule(s) offered. A dentist can apply for participation when s/he has a license in the state where the doctor is interested in becoming an In Network Provider. To become credentialed, you will be required to provide several documents.
Should you choose Type 1 NPI or Type 2 NPI? One of the most confusing decisions for the dentist is choosing between a Type 1 NPI verses a Type 2 NPI number. A Type 1 NPI is required if a dentist is putting his or her social security number on the dental insurance claim forms and is a solo practitioner, whereas both a Type 1 and a Type 2 are needed if the practice’s name and Tax Identification Number (TIN) are used for billing purposes. If the dentist owns multiple locations, billing under separate TINs, an additional Type 2 is needed for each office.You can find additional information on Type 1 and Type 2 NPI HERE.
The next step in the process is to establish a Usual Customary Rate (UCR) for your practice or evaluate your current one. A UCR is the charge for dental services that is consistent with the average rate or charge identical or similar services in a geographical area.
It is vital to be competitive within your own zip code and specialty. A fee schedule analysis will show if you are competitive, and you will be given percentages to choose from. This can be requested through companies such as McKenzie Management. Your UCR should be billed on all claim forms to all dental plans regardless of your participation. In doing so, you are telling the dental plans that this is the fee you charge for each procedure. This will help to create a Reasonable Customary Rate (RCR) for your area that will benefit the entire dental industry.
Once you have become an In Network Provider you will be listed in the dental provider directories. Patients will utilize their dental plan directories to look for a dentist close to their home or work to obtain the In Network insurance benefit. They have the capability to search the Internet for their plan’s participating providers by zip code, name or specialty. If your name does not appear on this listing, you more than likely will never have the opportunity to obtain this person as a new patient. Being listed as a provider is a great source of marketing for your practice and could assist with filling empty chair time as well.
Keep in mind that a “group” is not credentialed, rather the individual dentists are. If a dentist is credentialed at another location, in most cases his/her credentialing will not transfer from one office to the next. Your participation is based on the TIN, the physical office address, and your dental license. If any one of these things changes you are considered to be an “Out of Network Provider” with most plans.
Even dentists with malpractice issues can most often become an In Network Provider. The process, however, may take a bit longer and it is based on the severity of any Malpractice case(s).
Credentialing is a specialty with many aspects that could either hinder or help your practice. Although it is very time consuming, it is imperative that you analyze all of your options. If you are not sure how to pursue this or don’t have the time to, make sure you seek assistance from companies or organizations that can direct you through this process.
Melanie can be reached via email at firstname.lastname@example.org or call (561) 422-9938Forward this article to a friend
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