By Cindy Hartwell, dental benefits analyst at CDA Practice Support
At least once a day I take a call from a member who is hiring an associate dentist for the first time. Their question is always the same: ”How do I bill plans when my associate/employee dentist performs the treatment?”
As we look at the proper way to bill for the treating dentist, remember that a dental claim is a legal binding document and, as such, all elements documented on the claim form must be accurate.
Today, many dental plans have adopted contracting based on the contract and compensation of the treating dentist, not just the billing (owner) dentist.
When billing a dental benefit plan, the information documented in the billing dentist or billing entity, treating dentist and treatment location sections of the claim must be accurate. If the treating dentist documented on the claim differs from the treating dentist noted in the patient’s chart, the dental-benefits industry considers this billing practice to be fraudulent billing because the treating dentist is misrepresented on the claim.
Bill properly by registering all treating dentists
Let’s review how a practice can bill properly by registering all treating dentists in the practice with a dental plan.
When adding a new treating dentist to the practice, the billing dentist should try to contact the dental plans well in advance of the associate’s start date to learn how to add the treating dentist to the plan’s system of records. This is done by either contracting them with the plan or listing them as an out-of-network dentist.
If the treating dentist will contract with plans, remember that in most cases the plan will consider the dentist as out of network until the plan completes the credentialing and contracting process. This means that many plans will treat the dentist applying to their network as out of network while the plan works to complete the application for that dentist.
Different plans, different contracting protocols
Keep in mind that the plans have different contracting protocols, including compensation. Determining a plan’s contract protocol well in advance, including how long it will take the plan to process the contract, is critical for a smooth transition when adding a treating dentist into the practice.
Also, not all PPO policies allow assignment of benefits when an uncontracted dentist performs the treatment, and this means the patient, rather than the practice, will receive payment for services provided. What's more, many plans will decrease a patient’s benefits when they see an out-of-network dentist. So, if the goal of the practice is to have the treating dentist in network with plans due to the previously mentioned factors, it is important to try to align their start date with the time frame the plan provides to contract them.
Considerations when adding a treating dentist to the practice
If your practice plans to add a treating dentist, here are some things to remember:
- The dentist who performs the treatment must be documented as such on the claim in the treating dentist section.
- If the treating dentist will be contracting with the dental benefit plan, the billing dentist should learn the plan’s contracting requirements and time frames.
- If improper billing is done, the billing dentist may be found in breach of contract with the dental plan and would be penalized for the improper billing i.e. misrepresenting the treating provider on the claim form.
- The billing dentist should follow the plan’s stated contractual obligations for reporting any treating dentist working in their practice.
- Some dental benefit plan contracts are portable, while others are not. If a contract is not portable, the dentist will be required to sign a new contract with the plan if they want to be an in-network dentist at a new location ― even if the dentist is currently contracted with a plan at another practice location.
Lastly, dental plans’ contracting and compensation rates change from time to time. Because of this, do not assume that the dentist being added to the practice will be offered the same contract or compensation of the billing dentist who contracted with the plan in the past.
To learn more about billing for an associate, see the related CDA Practice Support resource.