The impact of dental benefit billing in the associate hiring process

By Ann Milar, CDA dental benefits analyst

With more than 700 dentists graduating from California dental schools recently, there is a wave of newly licensed professionals surfing the web and hitting the streets in search of job opportunities as associates in dental practices around the state. Simultaneously, more experienced CDA members may be expanding their practices by bringing in associate dentists as part of their long-term strategic plan.

The issues surrounding dental benefit plan billing can become more confusing for the dentist(s) and office teams due to the new addition of a dentist to a practice. Below are several considerations the owner and associate should take into account as they enter this new realm.

Address billing issues and dental benefit plan contracting issues in the Associate Agreement to avoid confusion between the owner dentist and associate.

For the protection of both parties involved, CDA recommends the use of an Associate Agreement to clearly outline the roles and responsibilities of both parties in the contractual relationship. The agreement should clearly outline the billing responsibilities for the work performed by the associate, along with any requirements that the associate contract with the same dental benefit plans as that of the owner dentist.

Sample language for inclusion in the agreement to address the contracting issue is provided below. A Sample Associate Agreement can be found on cda.org.

It is a material condition of the commencement and continuation of this Agreement and Associate’s continued employment under this Agreement that Associate shall use his best efforts to become qualified, credentialed and a preferred provider or obtain position of a similar nature with all dental benefit plan companies (“Dental Plans”) as required by Owner (“Preferred Provider”). Associate hereby agrees to submit all Dental Plans’ required information to obtain Preferred Provider status within fifteen (15) days of the Commencement Date and to obtain Preferred Provider status within forty-five (45) days of the Commencement Date. In the event Associate is unable or unwilling to obtain Preferred Provider status with one or more of the Dental Plans, Owner may, at its sole discretion, terminate this Agreement without any notice to Associate.     

Use the proper tools to report and bill for treatment accurately

It is essential that dental offices utilize the proper billing tools to ensure prompt payment. These include the current versions of the American Dental Association (ADA) claim form (J430D© 2012) and the ADA’s Current Dental Terminology codes (CDT 2014).

Recent versions of the ADA claim form provide areas for the “Billing Dentist or Dental Entity” as well as the “Treating Dentist and Treatment Location Information.” The information provided under “Billing Entity” should reflect the individual dentist’s name or the name of the group practice/corporation responsible for billing (usually that of the owner dentist). The information provided in this section may or may not be the treating dentist. In the “Treating Dentist and Treatment Location Information” area of the claim form, all information should reflect that of the treating dentist, whether it is the associate or owner dentist. Failure to accurately report the treating dentist on the claim form is considered fraudulent billing and demonstrates unprofessional conduct, both of which are punishable by law.

Contracting with plans takes time

Dental plan provider contracts are by provider and by location. A dentist who is associating with a new practice will need to notify any plans for which he or she is a contracted provider and let the plan know that he or she wishes to add a new location. This may require the dentist to sign a separate provider agreement for that new location.

For a dentist who is contracting with a plan for the first time, the process begins with credentialing. To become a contracted and credentialed dentist with a plan, this generally includes the completion of an application and submission of supporting documentation that must be verified and approved by the plan before the dentist is added to the plan’s network. Depending on the plan’s backlog, it can easily take four to six weeks for a new dentist to become a credentialed provider.

To each his own

As referenced above, dental plan provider agreements are by provider and by location, therefore, the contractual terms an owner dentist has with a dental plan as a participating provider will not necessarily be the same terms for the associate dentist should he or she contract with the same plan.

Newly contracting dentists are encouraged to review their dental plan provider agreements, fee schedules and supporting documentation carefully to ensure they understand the requirements of their participation. Additional tools and resources to assist with evaluating dental plan agreements can be found on cda.org.

Understand the dental plan’s payment rules

Most dental plans review claims for payment and determine benefits payable based on whether the treating dentist is a contracted provider, not the billing dentist or dental entity. If the treating dentist is out of network or a nonparticipating provider, dental plans apply the benefits accordingly. This may include refusing assignment of benefits to nonparticipating providers, hence the payment being mailed to the patient instead of the dental practice.

Additionally, plans will spell out their payment and processing guidelines in either a Dentist Handbook or Provider Guide of some sort. Review these carefully before signing the participating provider contract and ensure your willingness to comply with the terms included.

Don’t be “that office”

Unfortunately, I do hear of instances when a dental practice has received a termination letter or notice from a plan as the result of failing to bill appropriately for treatment rendered by the associate in the practice. This notice is usually accompanied by a request for a refund from the dental practice for the work that was incorrectly billed, sometimes to the tune of $100,000 or more.  

Dental plans conduct office and claim audits to verify that charting, billing and coding is in alignment with the benefits paid on behalf of their enrollee (your patient). It is important that dental offices revisit their system of checks and balances to ensure patient charts, billing records, claim submissions and appointment schedules correctly reflect the provider who actually rendered treatment.

Regardless of a dentist’s (or his or her staff members’) intent, failing to correctly document the treating dentist information on a claim form can have considerable consequences to the dentists and dental practice involved.

Additional dental benefit and other practice resources are available on cda.org/practicesupport.