It wasn’t that long ago that dental plans almost universally paid claims based on the contract status of the practice owner. Associate dentists would treat the patient, and the office would submit the claim with only the owner’s information and the plans would pay based on the contract with the practice owner. This is not the case today. Now the standard ADA claim form has fields for the billing provider and the treating provider’s information. Additionally, plans have moved toward payment based on the contract status of the dentist who provided the treatment and not that of the billing provider’s contract.
What's more, licensed healthcare plans are required to monitor the qualifications of their contracted providers and follow National Committee on Quality Assurance (NCQA) standards. During the credentialing of a provider, the plan must collect and verify an applicant’s professional qualifications, e.g. relevant training, licensure, certification, and/or registration to practice in a health care field and academic background, etc.
While the desire to bill using only the contracted owner’s information is understandable, especially if there is a difference in how the owner is contracted and paid versus how an associate will be contracted and paid, it still does not make it right.
Correct billing when an associate has provided the treatment can safeguard your practice. Plans are becoming more aggressive in auditing contracted dentists. Let’s look at a potential scenario of how incorrectly billing treatment provided by an associate could negatively impact your practice. Here is the scenario: An office bills a claim to a plan and fails to document the associate’s license number and type 1 NPI in the treating section of the claim. The claim is submitted to the plan with the contracted billing provider’s license number and type 1 NPI in the treating section of the claim. Based on the information on the claim, which is a legal document, the plan pays the claim as in network. Later, the office is audited by the plan and it is identified during the audit that per the patient’s record the treatment was actually provided by the noncontracted associate. The plan could recoup the monies they paid to the business as in network as the treatment provided was not actually provided by the contracted provider.
To avoid having this happen in your practice, read on to learn more about proper billing and contracting when an associate performs treatment in your practice.
You will need to reach out to each plan to determine their policies and procedures for contracting and/or adding an associate to their system of record. It is recommended that you connect with the plan’s professional relations or contracting departments as these departments often contract the providers.
Important note: Do not assume that the associate will be contracted and reimbursed the same as the contracted billing dentist. Plans can and do change their contract and reimbursement rates from time to time. During your communication with the plans, you should ask specific contract questions. Below are just a few questions you may want to ask.
Reimbursement rates can differ for an in-network versus out-of-network rendering provider. Keep in mind that this could cause confusion for the practice billing administrator and the patient regarding how a claim is processed and paid. In many cases, a patient will have a higher out-of-pocket expense when treatment is provided by a non-contracted treating provider. In addition, it is extremely important to check with each plan to see if an out-of-network provider will receive direct payment from the plan as some plans/groups will not allow assignment of benefits to an out-of-network provider, even if the billing provider is in contract with the plan.
Whether you decide to contract the associate as an in-network or out-of-network provider, it is recommended that the decision be documented in the associate agreement between the practice owner and potential associate.
There are many ways to submit a claim today, from paper, online plan portal to electronic and the list goes on.
However, no matter how you decide to submit for payment, there are certain elements that must be documented when billing.
Considerations When Hiring an Associate Checklist
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