How to contract with and bill for associates

As the dental marketplace continues to change, hiring associates and having a multidentist practice is increasingly more common. CDA Practice Support frequently receives inquiries from members regarding how to correctly bill for associate dentists providing treatment in their practice.

The version of the current ADA claim form provides clearly identifiable areas to report billing entity and treating provider information. It is important that dental practices accurately report treating provider information on the claim form, as it is considered unprofessional conduct and a fraudulent billing practice to do otherwise when the rendering of treatment was different from the billing provider. Plans almost universally now pay claims based on the contract status of the treating dentist. Even if the billing provider — the practice owner — is contracted with a plan, if the treating associate dentist is not contracted with the patient's dental plan, the claim will be paid according the plan's out-of-network fee schedule.

It is not recommended to use older versions of claim forms as they do not provide adequate areas for reporting treating provider information. For practices that have multiple treating dentists, it is recommended to move to an updated form. Using these older claim form versions does not dismiss a practice's requirement to report accurate treating provider information.

A sample claim form along with complete claim form instructions are available within the "Publications" tab on the ADA's website. Here is the specific instruction for completing the ADA claim form based on the dental practice structure:

Billing for a corporation or a group: 
Box 48: Enter the billing entity, corporate or group name and address 
Box 49: Enter the type 2 NPI for corporation or group 
Box 50: Leave blank, unless this is for an individual 
Box 51: Enter the entity's tax identification number if this is a group practice 
Box 54: Enter the Type 1NPI of the individual treating dentist
Box 56A: Enter specialty information (if applicable) of the treating dentist 

If the provider is a sole proprietor: 
Box 48: Enter the name of the dental entity 
Box 49: Enter a Type 2 NPI when the claim is submitted by an incorporated individual; unincorporated practices may enter the individual practitioner's Type 1 NPI 
Box 50: If the billing dentist is an individual, enter the dentist's license number 
Box 51: Enter the Social Security number or TIN if the billing dentist is unincorporated; enter the corporation TIN if the practice is incorporated
Box 54: Enter the treating dentist's Type 1 NPI 
Box 56A: Enter the specialty information for the professional who delivered the treatment 

The details are in the associate agreement
Is the associate expected to become a contracted provider with the dental plans the practice owner is contracted with? This detail should be addressed in the associate agreement between the practice owner and potential associate. There may be instances when the practice owner may be contracted with a particular plan but the associate is not contracted. Since the reimbursement rates differ for in-network providers versus out-of-network providers, based on whether the treating provider is contracted with the plan, this can cause confusion for both the practice-billing administrator and the patient.

The claim can be processed and paid differently for out-of-network providers, ultimately affecting the patient's financial responsibility. Generally, in-network or participating providers receive direct payment from the plan; however, some plans refuse to allow assignment of benefits to nonparticipating providers, resulting in the patient receiving reimbursement. This will be the case even when the billing provider is contracted with the plan.  It is best to check with the specific plans regarding this scenario and any other contracting rules.

Due to changes in the dental benefit marketplace, and changes in benefits made available to their enrollees, it may be the case that a plan may not make available to an associate the same contract the owner has. If the associate is offered a contract different from the contract the owner has, the practice owner should be aware that the fee schedule connected to the plan the associate is contracting with could be different. 

Why it's important to notify plans when an associate is hired

Most plans require they be notified that an associate is working under a billing entity or corporation, even if the associate will not be contracting with the plan and remains out of network. How the various dental plans contract with associates is an individual, case-by-case, consideration — there is not a standard policy that all plans follow. When a practice hires an associate, the practice must contact each plan the practice wants the associate contracted with to determine how best to proceed. Plans will need to update their claims processing system and associate the treating dentist to the billing entity or corporation to prevent claim rejection.

The majority of dental plans have changed the way they contract with and pay for care provided by dental practice associates. These changes have largely occurred in response to changing realities in the marketplace. These changes have also created challenges for dental practices, in some cases necessitating that practices can not be run the way they had been in the past.

Neither CDA nor state insurance regulators can control the business decisions made by dental plans in the face of shifting market realities. What organized dentistry seeks to do is to assist dentists in making wise business decisions to adjust to these realities. CDA Practice Support can help its members with these challenges. Contact Practice Support at 916.554.5990.

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