How to handle credentialing for your new dental practice

What is insurance credentialing?

Credentialing is the process that gives healthcare providers (including dentists) access to join insurance networks so they can provide treatment to patients under those plans.  In addition, if you are Fee for service or out of network, W9 submission and your NPI information are needed to receive reimbursements for the treatment rendered.

Want to treat patients with Blue Cross insurance? You’ll need Blue Cross credentialing. Cigna patients? You guessed it: you’ll need to get credentialed with Cigna. Sometimes you have to repeat for every single insurance network that you care to join. However, there is also a strategy that can be done in order to “pick up” some insurance companies such as Aetna, Metlife, and Cigna through umbrella networks and best part, reimbursed with higher fees.

What is an umbrella network? It is when multiple PPO insurance carriers fall under one umbrella network’s provider fee schedule which is usually higher than directly being contracted with one insurance company. The shared network agreements are constantly changing and differ from state to state and even zip code to zip code so it is always best to work with an insurance credentialing expert/company.

It’s tedious, but worth it (to do your research and homework before credentialing for every insurance company. There could be other network opportunities to help your bottom line). Many of your target customers are looking for a dentist that accepts their insurance, and will base their decision on that factor. The more networks you join, the wider your net that you cast for potential patients.

What is the process of insurance credentialing?

The basic credentialing process is pretty straightforward on the surface: have a business entity, apply to be in-network with the same insurance companies the seller is in-network with, and get credentialed.

Here’s how the process looks when you’re acquiring a practice. You should start this during the due diligence phase, after you’ve submitted your letter of intent to buy, and you and the seller have signed it.

Get a list of all insurance plans the practice currently takes. You’ll need to submit credentialing applications to each.

1. Round up details about the practice’s licenses, your dental education credentials, hospital privileges, DEA certificate, sedation permits and malpractice coverage. The application on CAQH will need all of this information. Insurers will review to verify you meet their clinician standards.
2. Create your CAQH profile online. This is a free central database to allow all healthcare providers to credential their information and eliminates redundant paperwork. ADA and CAQH have partnered together to make this easy for providers. You do not have to be an ADA member to use this free database. IT even will send reminders when attestation paperwork is due so you can continue to be a provider.
3. Get a list of all insurance plans the practice currently takes. You will review your data on CAQH and download the forms needed for the companies or umbrella networks you plan to credential with. Remember that if you are want to continue to be out of network with an insurance company, you will still need to submit a W9 to that insurance company.
4. Submit applications and documents to each insurance company in the CAQH (most plans and even Medicaid plans accept the CAQH application) Call the insurance’s provider relations line with any questions. Some states will require a state mandated application as well.
5. It may take 4-12 weeks for approval. Continuously follow up if you don’t hear back and write down the name of the rep and time if you call versus emailing. Get help from staff who credentialed with these plans before.
6. Never take the first fee schedule they offer you. Always negotiate or at least the top 10-20 codes (found in your PPA report done by DBA)

What networks should I get credentialed with?

I recommend you get started with the networks the practice is already credentialed with. After you’ve transitioned to running the business, you can always add additional networks or drop the lowest reimbursing insurances.

Here are the big ones to think about:

• Delta Dental. The largest dental insurance provider in the US. Their plans cover more than 80 million people nationally. There is a PPO network and Premier network. More and more states are not allowing new providers to join the Premier status which has higher reimbursement rates.
• UnitedHealthcare. One of the largest medical insurers that also offers dental plans. They have large market share across commercial, Medicare, and Medicaid plans.
• Aetna. Major national insurer for medical, dental, and other health plans. Their dental networks include over 413,000 dentists. Aetna can often be under umbrella networks.
• Cigna. Global health services company that provides dental insurance plans to over 5 million members. Often pays very well to out of network providers.
• Humana. Leading health insurer with dental coverage for around 5 million members.
• MetLife. Insurance company providing dental benefits to over 20 million people. There is Metlife PDP and Metlife PDP plus. Often pays well to out of network providers.
• Blue Cross Blue Shield (BCBS). Association of 36 independent BCBS companies offering dental plans in all 50 states.
• Guardian. Top 10 dental insurance provider in the U.S. with over 143,000 dentists in network.

Speaking about insurance plans, here’s what you need to know about Delta Premier:

Start early to cut down on stress

First, if you have some level of anxiety around insurance credentialing, you’re normal. I don’t think I’ve worked with a buyer yet who has ever said, “Oh yeah, I’m totally on top of credentialing and I have zero questions or issues.” Everyone has some level of stress.

Remember: everyone makes it through the process, and you will too.

The best way I know to alleviate concerns around insurance credentialing is to start the process as soon as possible. Usually, this will be immediately after you and the seller both sign a letter of intent. Once that LOI is signed, you need to start on credentialing. Give yourself the maximum amount of time to manage the steps in the process.

Yes, it’s in both the insurance company’s and your interests to be credentialed with them, but you will have a much greater sense of urgency than they will. Starting early means you’re not counting on their speed—or stressing as much over the lack thereof.

Can I bill under the seller’s info?

Wouldn’t it be nice if you had some time to coast along under the seller’s credentialing? It would allow you to settle in, and handle credentialing after the stress and hustle of closing on the practice.

I can’t offer any legal advice on the advisability of this or any other matter. But I will say that most buyers do bill under the seller’s information in some form or another immediately after purchasing a practice. This is often one of the main reasons a buyer is interested in a seller sticking around for a month or two after closing.

One insurance expert shared with me that even if a buyer submits a claim form under the seller’s tax ID number, they still need to disclose they are the provider rendering treatment. The ADA claim form has a location for the billing entity (Practice Name, Tax ID Number, NPI2, and Billing Address) and a separate location to disclose the providing doctor (Provider Name, License Number, NPI1).

To be reimbursed by insurance networks, the “provider,” not just the business entity, must be credentialed (Medicaid requires both the entity and provider to be credentialed).

Keep in mind the insurance company will issue a 1099 to the entity that submitted claims each year, so the seller has an incentive not to allow a lot of submissions under their number.

Bottom line: it’s best to get your own credentialing handled ASAP.

How long does insurance credentialing take?

30-60 days is the average timeframe, from application submission to full credentialing. The worst insurance companies can take up to 120 days (or in really extreme cases, longer). And Medicaid can be even longer. Have a plan in case this happens and consult with an expert to understand your options.

As a general rule, if you’re an associate in the office already, or if you’re already credentialed as an associate with a particular insurance company, the total time to get through the process tends to be shorter.

Can the staff help me with credentialing?

Yes, the staff can often be a big help when dealing with insurance companies. They’re often talking with them daily. However, there is one potentially huge issue that comes up around the staff. The staff may not know you’re coming.

It’s common for a seller and broker to want to keep the transition a secret from staff before closing. But, insurance companies will call the office with questions related to new providers being credentialed. This presents an obvious problem: how do you start on credentialing if it has to be a secret from the office?

Honestly, this is a tough one. Some sellers will instruct the insurance company to only call them directly and send mail to their home address.

My personal preference is to push the seller to bite the bullet and start to let a few select people know that ownership of the office is changing. It is unreasonable for a seller to expect you to be out of network for months after a transition without some kind of accommodation or plan.

Work with your team to come up with a solution as soon as you have an LOI in place. On the CAQH portal, you can set it up to where staff members can have a separate login to help with the doctor’s credentialing which can save a lot of your time.

Don’t be afraid to get help

Besides an accountant and attorney, think about retaining an insurance expert. There are a few companies now that specialize in helping through the types of insurance questions and issues buyers have in a transition. They can guide you through the process and negotiate with the insurance companies.

Having professional help through the process can be a huge stress relief and even get you in-network faster than doing it yourself. In my mind, the big value comes in the negotiation portion and how they can strategize on umbrella networks and shared PPO agreements. If they’re able to secure 5-10% higher reimbursement rates for you on some of the common submission codes, that insurance expert will easily pay for themselves in your first year of ownership. They can identify networking opportunities so you can avoid being over contracted and ultimately increase your collections. Let me know if you’d like a referral to a good insurance expert that works with buyers.

The bottom line

Insurance credentialing is complex, slightly different for everyone, and very important. There are a lot of rules and laws to be aware of and follow. Start early, have a plan in place with the seller, and consider getting some professional help with this area. ADA, Dental Facebook insurance groups, and our resident past dental practice owners at DBA are all free resources to you!