This article was authored by Cindy Hartwell, dental benefits analyst at CDA Practice Support.
As the dental-benefits analyst for CDA Practice Support, my job is to help dentists navigate the ever-changing benefits marketplace and this entails clearing up misconceptions that could place a dentist at risk. Here, we’ll cover how to properly bill dental-benefit plans when a dentist performs the treatment.
As we explore the proper way to bill for the treating dentist, keep in mind that a claim is a legal binding document and, as such, all elements documented on the claim form must be accurate.
In today’s dental-benefits marketplace, many plans have adopted contracting based on the contract of the treating dentist, not just the billing (owner) dentist. When billing a benefit plan, the information documented on the claim in the billing dentist or billing entity, treating dentist and treatment location sections must all 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.
It is important to understand that many plans use analytic software to monitor a dentist’s claim-utilization patterns. These analytics can be used to compare the treatment patterns of a dentist to their peers and identify a dentist who stands out.
One way a billing dentist might stand out is when they are a contracted dentist with a plan but have an uncontracted dentist treating enrollees of that plan in their practice, and yet the billing dentist bills the plan noting the contracted billing dentist as the treating dentist on the claim. Because the treatment was actually performed by the uncontracted dentist, this type of improper billing can cause a rise in that billing dentist’s claim-utilization pattern when compared to a peer who is also a contracted dentist with the plan but has no one else working in their practice. This overutilization pattern can trigger a plan audit. If discovered, such billing can be costly, as the plan could recoup any monies paid beyond the out-of-network benefits under the policy because the treatment was provided by an out-of-network, not in-network, dentist. The billing dentist or billing entity also runs the risk of being terminated from the network due to a breach of contract.
Let’s look at how a practice can bill properly by registering all treating dentists in the practice with a plan to avoid the previously mentioned risks.
When adding a new treating dentist to the practice, the billing dentist should contact the plans well in advance of their start date to learn how to add the treating dentist to the plan’s system of records 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 contracting process is completed by the plan. 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. Do not assume that contracting is one-size-fits-all. The dental-benefits marketplace is very complex and plans have different contracting protocols, including for 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 of adding a treating dentist into the practice.
Also, keep in mind that not all plans will 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.
If your practice plans to add a treating dentist, here are some things to remember:
Also, not all plans’ contracts are portable; in fact, many are location-specific, meaning that even if the dentist is currently contracted with a plan at another practice location, they will be required to sign a new contract with the plan if they wanted to be an in-network dentist at a new location.
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 and/or compensation of the billing dentist who contracted with the plan in the past.
For additional information on billing for an associate, access the CDA Practice Support resource “Considerations When Billing for an Associate.”
For more assistance with these and other dental-benefit questions, contact CDA Practice Support at 800.232.7645 or email [email protected].