Billing Insurance For Associate Dentists: Navigating The Reimbursement Journey

Billing insurance for an associate dentist can be a complex process, and it's important to understand the billing rules and insurance company requirements. One key question is whether the associate dentist should be credentialed with the insurance company before providing services. While it is generally recommended that they are credentialed beforehand, this can cause delays and operational challenges for dental practices. An alternative is to bill on an incident-to basis under the National Provider Identifier (NPI) of a credentialed, supervising provider. However, not all commercial payors follow this rule, so it's crucial to understand each insurance company's specific rules to avoid compliance risks. Dental billing companies and legal counsel can provide valuable support in navigating these complexities and ensuring accurate and timely billing and reimbursement.

Credentialing and billing for a non-credentialed associate dentist

Credentialing is the process of a dentist entering into a contract with an insurance carrier. It involves the insurance provider reviewing and verifying the dentist's credentials, such as their education, training, and professional history. This is known as the "Vetting Process". Once the dentist's application is approved, they are bound to the contractual agreement with the insurance provider, agreeing to follow their fee schedules and guidelines for patient copayments.

If you are adding a new associate dentist to your practice, it is important to start the credentialing process immediately to avoid payment delays. The credentialing process can be lengthy, taking up to several months, and claims submitted during this time are considered out-of-network.

Understand the Credentialing Process:

• Research the requirements and gather the necessary documentation, such as licensure, insurance coverage, and board certifications.
• Contact the insurance network providers to obtain credentialing applications and inquire about their specific processes.
• Carefully complete and submit the applications, including all required documentation.
• Establish and maintain a CAQH (Council for Affordable Quality Healthcare) profile, which helps streamline the credentialing process with multiple organizations.
• Follow up periodically with the insurance providers to check the status of your application.

Billing for a Non-Credentialed Associate Dentist:

• Until your associate dentist is credentialed, they may be considered a non-participating or out-of-network provider. This means that the insurance company may not reimburse for their services.
• Review the commercial payor contracts and policies of each insurance company to understand their rules regarding billing for non-credentialed providers.
• If the payor allows, you may be able to bill on an "incident-to" basis under the National Provider Identifier (NPI) of a credentialed provider who supervises the non-credentialed associate. However, not all commercial payors follow this rule, so it is important to check with each insurance company.
• Seek legal counsel to ensure compliance and avoid any unforeseen risks associated with billing for a non-credentialed provider.

Tips for a Smooth Transition:

• Plan ahead and allow sufficient time for the credentialing process before the associate dentist joins your practice.
• If possible, have the associate dentist obtain credentialing before providing services to patients to avoid delays in reimbursement.
• Be aware of the compliance risks associated with billing for a non-credentialed provider and consult legal counsel if needed.
• Maintain open communication between your practice, the associate dentist, and the insurance providers to ensure a smooth and efficient credentialing and billing process.

Understanding the difference between an associate and an independent contractor

The distinction between an associate and an independent contractor in the dental industry is important, especially in terms of IRS regulations. Dental associates are typically considered employees if their employer has the right to control how they perform their duties. This means the employer decides:

• When and where they work
• The equipment and supplies they use
• The processes they follow when doing procedures
• Who they work with
• The patients they are assigned

Dental associates are hired under contract either as an employee or an independent contractor. As an employee, a dental associate will:

• Receive an hourly rate or a flat salary
• Have compensation based on a percentage of gross revenue
• Be provided with equipment, supplies, and tools needed to perform their work
• Have their patient schedules coordinated by office staff
• Be eligible for benefits such as health, vision, dental, life, retirement, and disability insurance at a reasonable cost
• Be responsible for their individual income tax returns (federal and state)
• Be eligible for worker's compensation benefits if hurt on the job
• Be eligible for short-term and long-term disability payments if this coverage is part of the employer's benefits program

On the other hand, an independent contractor has a very different arrangement. As an independent contractor, a dental associate will:

• Be a self-employed individual providing services to patients in the setting of the dental practice or office
• Set their own schedule while growing and managing their patient base
• Purchase and manage their health, dental, vision, and other insurance benefits, as well as their retirement savings
• Pay their job-related expenses, including liability insurance, training, travel, and professional membership dues
• Prepare and submit their payroll and income taxes, possibly using a paid preparer or accountant to comply with self-employment tax laws and regulations
• Depending on their contract, they may be required to purchase some supplies, with rights to use the practice's systems and equipment

While being an independent contractor offers more freedom and flexibility, it also comes with more responsibilities and expenses. It is important to carefully consider the advantages and disadvantages of each option before making a decision.

Getting the associate contracted/in-network

The first step in getting an associate dentist contracted and in-network is to determine their employment status. Associate dentists can be hired as either full-time employees or independent contractors. This distinction carries significant implications for both the employer and employee, including the level of control exerted by the practice over the associate's work, the benefits offered, and tax-related obligations.

Once the employment status is established, the next step is to draft a comprehensive dental associate contract or dental employment agreement. This contract should outline the terms and conditions of the associate's employment, including their role, responsibilities, qualifications, compensation, benefits, term and termination, insurance, non-competition clauses, confidentiality provisions, and dispute resolution procedures. It is advisable to consult with an employment lawyer to ensure the contract complies with relevant laws and adequately protects the rights of both parties.

For an associate dentist to become in-network with insurance companies, they must enter into contractual agreements with these insurers. This process typically involves submitting specific documentation, including a PPO contract, agreement, and attestation, along with the doctor's credentials and employment history. The timeline for this process may vary depending on whether the associate has previously been vetted and approved as a preferred provider.

It is worth noting that being in-network with insurance companies comes with certain pros and cons. On the one hand, it provides access to a wider patient base and promotes affordability for patients. On the other hand, it may entail pre-established fees for services, potentially limiting the dentist's ability to charge higher rates.

Associate PPO reimbursements

When a General Practitioner (GP) adds another GP to their practice, it is advisable to submit current fee schedules with the applications to ensure the associate is placed on the office's reimbursements. It is important to understand the current participation, including plan-level participation and direct contracts vs leasing arrangements, to mirror the same with the associate.

If a GP adds a Periodontist, some reimbursements will differ since some insurance companies and network umbrellas have separate fee schedules for specialists.

PPO stands for Preferred Provider Organization. It is a type of managed care health insurance plan. PPOs got this name because they have lists of healthcare providers that they prefer you to use. If you get your health care from these preferred providers, you pay less.

PPOs are subscription-based medical care arrangements. A membership allows a substantial discount below the regularly charged rates of the designated professionals partnered with the organization. PPOs earn money by charging an access fee to the insurance company for the use of their network. They negotiate with providers to set fee schedules and handle disputes between insurers and providers.

PPOs offer discounted fee schedules for health care providers in exchange for a guaranteed number of customers, who receive lower out-of-pocket expenses for services with a co-payment. Disincentives in the forms of higher deductibles and co-payments are applied for going outside of the approved network. Service providers can bill the PPO even if they are not a member of the network but may receive a lower rate of reimbursement for out-of-network services.

Medical codes and dental codes

Medical coding and dental coding are both essential for billing insurance for dental procedures. While medical coding relies on Current Procedural Terminology (CPT), medical billing codes for dental procedures use Current Dental Terminology (CDT). The CDT, maintained by the American Dental Association (ADA), contains all the dental procedure codes required to code each dental procedure for submission to a specific dental insurance plan.

CDT codes are a set of alphanumeric medical codes for dental procedures that cover oral health and dentistry. Each procedural code begins with the letter "D" (the procedure code) and is followed by four numbers (the nomenclature). The CDT code set is categorised by types of service, including removable prosthodontics, maxillofacial prosthetics, fixed prosthodontics, oral and maxillofacial surgery, and adjunctive general services.

The U.S. federal government has designated the CDT Code as the national terminology for reporting dental services to third-party payers. Providers typically have three types of coverage options for billing: in-network, out-of-network, or HIPAA-compliant electronic communications/transactions. If the claim will be billed to dental insurance, CDT dental codes are used. However, if a patient receives dental care related to a medical condition, medical insurance could be billed depending on the specifics of their policy coverage.

It is important to note that most medical plans contain stipulations that eliminate coverage for any treatment involving "teeth". Typically, the dental claim is submitted first, and if it is denied, a medical claim is then submitted.

When submitting dental claims for reimbursement, insurance companies often require supporting documentation to validate the services provided, such as treatment notes, X-rays, treatment plans, and diagnostic reports.

Healthcare providers use three different coding systems: CPT, HCPCS (Healthcare Common Procedure Coding System), and ICD (International Classification of Diseases) codes. CPT codes are developed and updated by the American Medical Association (AMA) and are required for healthcare providers to receive reimbursement from health plans. HCPCS codes are used by Medicare and include CPT codes (Level I) and additional codes for products, supplies, and services not covered under CPT (Level II). ICD codes, developed by the World Health Organization (WHO), identify the patient's health condition or diagnosis and are often used in combination with CPT codes to ensure that the services received align with the patient's diagnosis.

Dental billing and coding can be complex and confusing, but accurate coding is critical to ensure prompt reimbursement and avoid legal problems due to alleged fraud.

Frequently asked questions