Some events in life, such as the birth of a child or certain medical procedures, can be planned or controlled. But there are times when circumstances are outside of our control, such as with injury or unexpected death.
In this resource, we address how your absence in the practice could result in dental claim processing issues and how having a plan of action in place can reduce complications during these times.
You might think that finding a substitute dentist cannot be that hard, and you might be correct. On the other hand, benefit plans today have moved toward payment of claims based on the contract status of the dentist who rendered the care rather than the contract status of the billing dentist. This can cause problems. If a plan processes with this type of contract policy and their system of record is unable to find a contractual relationship between the billing dentist, practice location and the temporary treating provider, the claim will not be processed as in network. The claim may be denied or, worse, paid as out of network with monies paid to the patient and not the office.
Each benefit plan has its own contracting policies and time frames for handling a temporary provider situation. Whether the need for a temporary dentist in the practice is foreseeable or not, reaching out as early as possible to the plans is necessary to avoid claims processing issues.
By law, in the event of death of the billing dentist, the practice has up to one year to operate under the business name of the deceased dentist. If one or more temporary dentists will be filling in while arrangements are made to sell and/or close the practice, each plan to which the late provider billed claims should be contacted to determine how to add the temporary
providers to the plan’s system of record. It is critical that all of the plans the deceased provider was in contract with be contacted first to avoid the previously mentioned out-of-network claims processing issues. CDA has a resource to help in the event of a provider’s unexpected death: Unexpected Death of a Dentist (Solo Practice) Checklist.
Additionally, it should never be assumed that even if the treating provider who is filling in is in contract with a plan, he or she will automatically be considered in network at another business and location without records in place linking them to that business and location. Many plans have adopted contracting policies based on the information documented in the Billing Dentist or Dental Entity and Treating Dentist and Treatment Location Information sections of the ADA claim form, and many processing systems look at the following information on the claim to determine contractual relationship:
Let’s look at a claim-processing example with the above-mentioned type of processing policy.
Dr. Smith is a contracted billing and treating provider for Smiles Dental Plan at his practice located at 123 Main Street in Smiles City, Calif.
Dr. Smith suffers an injury that will keep him out of the office for six weeks. Because he needs to find a dentist to fill in for him, he calls his good friend Dr. Jones who is also in contract with Smiles Dental Plan but under his own business located at 456 East Avenue in Smiles City.
One might assume that Dr. Jones’ contract with Smiles Dental Plan is portable, meaning a dentist may take their contract wherever they practice in California. Dr. Jones acts on this assumption and starts working at Dr. Smith’s office without notifying the plan and setting up a temporary arrangement. Here is where assuming can lead to an office-billing nightmare.
Smiles Dental Plan’s contracting policy associates three key items — billing entity/provider, practice location and treating provider. Dr. Smith’s office documents the following on the claim: Dr. Smith as the billing provider/entity, the practice address of 123 Main Street in Smiles City and Dr. Jones as the treating provider. The claim is then sent in for processing. The processing system at Smiles Dental Plan finds the billing provider/entity Dr. Smith and locates the 123 Main Street location, but a contractual relationship linking Dr. Jones to the billing entity and location cannot be found. In this case, depending on the processing policy of Smiles Dental Plan, the plan will either deny the claim or process it as out of network.
In other words, until a plan that processes with this type of policy has a record of contractual relationship linking the treating dentist Dr. Jones to the billing entity Dr. Smith at 123 Main Street in Smiles City, Calif., the plan will not process the claim as in network.
To avoid this situation, contact plans as soon as possible — and before you send the first claim. When contacting the plans, it is best to contact their professional relations or contracting department directly rather than the contact center, which is usually not equipped to assist with these situations.
For assistance with any of the scenarios described in this resource, please contact CDA Practice Support at 800.232.7645.