Credentialing and the In and Out of Network Provider

Estela Vargas, CRDH, CEO Remote Sourcing

Simply stated, when you sign a contract to be within the network of the insurance companies' selected providers (in-network), there are rules for consistency and regulations to follow.  You have greater control over what you charge if you are outside the organization, not contracted (out-of-network). You can operate more independently without the insurance company's policies restricting you.

Dental credentialing is on an individual basis. Multiple dentists may practice in one location, and each may decide whether to be in-network or out-of-network.  Every dentist must be credentialed individually with each insurance provider. The credentialing process or provider enrollment consists of two phases: credentialing and contracting.

Insurance plan providers verify your formal education, professional history, exceptional training, and licensing during the credentialing process to ensure you meet the internal requirements for an in-network provider. In the next step,  the insurance company issues an agreement outlining specific terms for the provider participation and receiving claim reimbursement.

A provider agreement is a requirement for in-network reimbursement. However, you may have the option to bill as an out-of-network provider until completing your credentialing. Unfortunately, the insurance company does not guarantee claim processing. Additionally, claim acceptance depends on the patient's out-of-network benefits.

To credential your dental practice with dental insurance companies, prepare a checklist(from the ADA)² of must-haves before beginning the credentialing process. Here are some of the items that you need to prepare:

Required Information:

• State license number(s).
• Professional liability Insurance (proof)
• Practice location information.
• Education and training information. Schools and dates.
• NPI Number.
• Anesthesia license.
• DEA (Drug Enforcement Administration) license.
• CDS (Controlled Dangerous Substances) license.
• Medicare numbers.
• Medicaid numbers.
• CAQH number.
• BLS (Basic Life Support) certification information.
• ACLS (Advanced Cardiovascular Life Support) certification.

 More information may be required depending on the state in which you practice. You may have to sign one or more Authorization, Attestation, and Release documents after attestation².

Credentialing an out-of-network dental provider is a process where the provider applies for contracts with insurance payors to become an “Out-Of-Network”(OON) provider. These providers are not part of the insurer’s network, meaning they will not receive reimbursement directly from the insurer but must bill their clients out of pocket.

How to Submit Claims for Out-of-Network Providers

• Use the Specialist’s(OON) UCR fees, not your insurance fees.
• Attach the Specialist’s W9 to the first few batches of claim forms.
• Preauthorization is highly recommended at least three weeks before the scheduled appointment. File the pre-authorization as soon as the patient is scheduled.
• Some insurance companies will require an additional form to submit with the out-of-network providers' information before processing the claims. I have seen Delta Dental hold OON claims until they receive their specific form filled out for OON providers.

The Dental Insurance Carrier Contract

It’s essential to thoroughly read and understand the insurance carrier contract before signing it. The contract language and stipulations will detail the participating plan, including fee schedules and the rules for charging patients.  Dentists often sign the contract document without fully understanding the contractual obligations. For example, signing the contract can permit the dental insurance carrier to audit the dental practice and documentation. Additionally, insurance carriers can determine if specific procedures are billable or not. Insurance payers will not allow dentists to bill the patient for a procedure(because of the contract) that would typically be billed if the dentist was out-of-network.

 Patients drive the In-Network vs. Out-of-Network bus.

Patients look to their dental insurance for affordable dental care and are wary of coinsurance or out-of-pocket costs. Patients can be depended on to ask, “What will my insurance cover?” Being transparent about anticipated expenses out of network is vital for patient communication. The network may not cover some procedures, so an out-of-network specialist is required. Out-of-network patients will generally pay higher out-of-pocket rates and fees1.

 Should you be an in-network provider?

1. Research and understand the top large employers in your city and county via a demographic study. Joining the major local businesses' insurance carrier will put your dental practice among a large, in-demand customer base.

1. Review the insurance carrier fee schedules. Are they fair?  Can you operate within their payout?

1. Know your competition and what the demand is for different insurance carriers.  Can you be selective and negotiate fees?

1. When buying a dental practice, you’ll likely choose the insurance carriers the former dentist participated in to include existing patients. Perform diligence to ensure the practice isn’t a losing situation with write-offs.

1. Are you credentialed already? If you have been working in a dental practice before buying or starting a new practice, you may need to fill out an update form for the insurance company. The contracts are with individual providers, so your contract (which may or may not include fee schedules) can be linked to multiple locations ¹.Remember, do not assume that your participation will automatically follow you once you submit a claim; you must undergo a credentialing process to get added to the new/additional location. ---- I have seen many doctors think it follows them and will be automatically linked.

In-network credentialing is often the best option for Providers who want to maximize their reimbursements and minimize the paperwork.

Healthcare providers might opt for In-Network Credentialing if

• they have a large patient base that uses the same insurer,
• if they want to offer services to insured individuals at negotiated rates
• if they're going to build relationships with insurers and expand their network of contracted payers,
• if they would like to create a more extensive patient base with the help of the insurance directory. Free marketing/advertising
• If added to multiple directories and search engines as an in-network provider.

Out-of-network credentialing can benefit those who want greater control over how much they charge and the services they provide. If you are considering or preparing your dental practice to go out of network with insurance, here are some tips to help prepare you and your dental practice to go out of network with insurance companies:

1. Review your contract with the insurance companies you’re in-network with.
2. Consider their fees versus what your future fees will be.
3. Notify your patients.

There are several scenarios where Out-of-Network Credentialing may be beneficial for a Healthcare Provider, such as when:

• They provide services that are not covered by the insurance company’s network.
• They require more flexibility in their payment terms.
• They want to offer services at a higher cost than what is provided by the In-Network Providers or
• They want to remain independent and not be bound by the rules of a more extensive network.

The best way to determine whether you should participate in In-Network or Out-of-Network is by contacting a Credentialing expert partner. Experienced professionals such as the knowledgeable credentialing experts at Remote Sourcing will help you make the correct decision by analyzing your practice needs.

References

1. Dental Provider Credentialing 101: Part I - Dental Support Essentials - Dentaltown. https://www.dentaltown.com/blog/post/6632/dental-provider-credentialing-101-part-i
2. “Your Credentialing Checklist, Get Started Today https://www.ada.org/topic/Credentialingpdf (ada.org)

Works Cited

Jolly, Sheri. “Dental Provider Credentialing 101: Part I - Dental Support Essentials.” Dentaltown, 12 March 2017, https://www.dentaltown.com/blog/post/6632/dental-provider-credentialing-101-part-i. Accessed 16 January 2024.