The Dental Billing Podcast

Credentialing vs. Contracting: What Dental Practices Need to Know

• Ericka Aguilar

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Credentialing versus contracting - these terms are often used interchangeably in dental offices, but as Ericka Aguilar explains in this essential episode, they represent entirely different processes with significant implications for your practice's compliance and financial health.

Credentialing is the verification process where insurance companies confirm a provider's qualifications, while contracting is the business agreement that follows, officially making a provider "in-network." Understanding this distinction is just the beginning of navigating the complex landscape of dental insurance billing.

The episode delivers a stark warning about one of the most dangerous practices happening in dental offices today: billing under another provider's NPI when that provider didn't perform the treatment. This typically occurs when practices are waiting for a new associate to complete the credentialing process. What many don't realize is that this practice constitutes insurance fraud, violating state and federal regulations. With insurance companies now employing AI and aggressive auditing techniques, the risks of massive recoupments, civil penalties, and even criminal charges have never been higher.

Erica also demystifies Locum Tenens arrangements, which provide a legitimate pathway for practices to maintain continuity of care when a provider is temporarily unavailable due to specific circumstances like maternity leave, disability, or death. However, these arrangements come with strict limitations that must be carefully followed to avoid compliance issues.

Through real-world examples and practical advice, this episode equips dental professionals with the knowledge to protect their practices while maintaining ethical standards. Whether you're a practice owner, office manager, or dental biller, the insights shared will help you navigate the credentialing process correctly, understand when Locum Tenens is appropriate, and implement documentation practices that keep your practice on the right side of compliance. Visit dentalbillingdoneright.com to learn more about setting up proper credentialing SOPs and claim auditing for your practice.



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Delta Dental Locum Tenens Form:

https://www1.deltadentalins.com/content/dam/ddins/en/pdf/dentists/locum-tenens-form.pdf





Speaker 1:

Hi friends, welcome back to another episode of the Dental Billing Podcast. It's me, erica Aguilar, your host, and today we're diving deep into a topic that confuses a lot of offices, and rightfully so. We don't really talk about this much. We're talking about credentialing, contracting and locum tenants, what they are, how they intersect and why misunderstanding these concepts can not only cost your practice money, but put your license and livelihood at risk. This is a long form episode meant to bring clarity. We're gonna lay it out step-by-step, with real examples and some really tough truths, maybe some not so popular opinions. So go grab a coffee. You're probably gonna wanna take notes and let's clear the air on all of this. Let's start off with credentialing versus contracting and what the differences are. Let's put the kibosh on all of the confusion around this. This is one of the topics that everyone thinks they understand until something goes wrong, stand until something goes wrong, and when it does go wrong, it goes really wrong. So most dental billers and even some practice owners toss around terms like credentialing and contracting interchangeably, but trust me, they're not the same at all. Today we're just going to cut through all that noise. So let's first start with credentialing.

Speaker 1:

Credentialing is the process of verifying a provider's qualification. So this means confirming licensure, malpractice coverage, education, background checks and clinical history. Think of it as the insurance company doing their due diligence to make sure that this person on the application is qualified to provide care to their members. Contracting, on the other hand, is the business side to this transaction. Once a provider has passed the credentialing phase, contracting is when the insurance company offers a fee schedule and a participation agreement that the dentist then signs. This is what officially makes them in network. So, to be clear, credentialing does not automatically make someone in network. You can be an out-of-network provider and still have to go through the credentialing process. You just chose not to sign the contract to be officially in network, so you can be fully credentialed and still be out of network if no contract is in place.

Speaker 1:

So I hope that clears the air for those of you that have in the past used that term or these terms interchangeably. I know I have in the past. Before I knew the difference between the two. I would refer to contracting as credentialing or credentialing as contracting and just kind of expected everybody to know what I was talking about. So I just want to make sure that we're clearing the air on that.

Speaker 1:

So let's say that you bring on a new associate and you submit their credentialing application to I don't know, let's just use the mafia Delta Dental. It takes a few weeks, sometimes a few months, and during that time the associate is not contracted, even if the credentialing phase is complete. If the contract isn't signed and returned and acknowledged by Delta Dental, that provider is not in network. So this is where the rubber meets the road. You need both pieces the credentialing I refer to that as the vetting and the contract I refer to as the deal. If you skip one, you're not just skating on thin ice, one, you're not just skating on thin ice, you guys, you're like literally diving into a frozen lake. Which brings me to my next point.

Speaker 1:

Let's talk about this dangerous workaround that I see a lot of offices risking their providers' licenses for, and that's billing under someone else's NPI. This is where a lot of offices go wrong and I've seen this too many times. They hire an associate, the credentialing process drags out and instead of delaying treatment or collecting out of network, laying treatment or collecting out of network, they start billing under the owner dentist NPI. Let me be very crystal clear this is insurance fraud, billing under another provider's NPI when that provider did not perform the treatment is a direct violation of state and federal regulations is a direct violation of state and federal regulations. It violates payer agreements and it puts your practice at enormous risk. And don't think you won't get caught, you guys. Today is a different world. The days of getting away with stuff like this are over, because insurance companies are utilizing AI and they are auditing more aggressively. They're also using metadata to cross-reference who was in the office, who signed the clinical notes, and even looking at which login was used in the practice management software. I could go down this rabbit hole, but I'm not going to. I just want to say this You're setting your practice up for a failed audit If you are using excuse me, if you're using an NPI from a provider that's not actually doing the work, from a provider that's not actually doing the work. This can lead to massive recoupments on the insurance company side, civil penalties and, in some cases, criminal charges. This isn't, these are not scare tactics, you guys. This stuff is already happening. They are utilizing aggressive methods to cross-reference whether or not we are billing under the correct provider's NPI. So be aware that this is happening.

Speaker 1:

So what do you do while you're waiting for an associate to be credentialed and contracted. So first and foremost, you have to jump on getting the associate credentialed right. We got to get that train going and in the meantime that associate and I know this is fact with Delta Dental the associate cannot see Delta Dental patients and I think this is what leads to the insurance fraud. You have to understand that the credentialing process is in place to ensure that we're not letting any Joe Schmo provide treatment that's not qualified to provide treatment to your patients. So credentialing is absolutely necessary. So when you have an associate that you've hired, get that credentialing process started right away and get them added to an existing contract so that they can be recognized as in-network providers at that location. Otherwise you're going to have to make sure that only contracted Delta dental associates are seeing those Delta dental patients. Otherwise you may have to delay treatment until they are officially on the plan.

Speaker 1:

Very popular opinion and I know that everybody wants us to come up with some magic wand and some term that we can put on a claim that allows a non-credentialed associate to see Delta dental patients and Delta is typically the number one plan that I've seen across the board. I think it's been very rare where I've seen an office whose number one payer is like Cigna or Aetna. For the most part I just see that Delta is the number one plan, meaning Delta has the most patients attached to that practice. So it makes it very difficult. I totally understand that practice. So it makes it very difficult. I totally understand that struggle. You don't want to violate contracts, you don't want to violate state and federal regulations. It's just really important and it's not worth it at the end of the day. So under no circumstance should you bill under another provider's NPI period.

Speaker 1:

Now let's talk a little bit about actually a lot bit about locum tenens and what this means. The goal of using a locum tenens provider is to ensure continuity of care without disrupting the in-network status of the office. A locum tenens dentist is a temporary provider. Think of it as a placeholder when the owner has an emergency, such as passing away, death, and we need to have a temporary provider in there while we prepare to sell the practice. Disability, which includes maternity leave, so a disability could be. Maybe we had some issues with the main provider's hands, maybe they needed surgery and they're going to be out on disability. We can get a temporary dentist in there without having to go through the full credentialing process, temporarily while the doctor recovers from that surgery. The surgery does need to qualify for disability benefits, qualify for disability benefits and, as long as it is considered a situation where the doctor the treating main treating provider is out on disability, we can then get an associate or a temporary dentist in there to ensure that we can continue to provide in-network care to our patients. That's the whole purpose of utilizing a locum tenens dentist. The temporary provider does not need to go through the full credentialing and contracting cycle and the claims can still be submitted under the regular provider with the appropriate modifiers or documentation. For those of you that are familiar with the changes on the 2024 claim form, you know that we have the ADA added sections where we can actually place a locum tenens dentist NPI number on the claim form indicating to the insurance company that this is a temporary dentist, and it's also been approved by that plan. So the plan should be aware that you're going to be submitting under a locum tenens NPI number because there is a process to kicking all of this off. So let me just illustrate how this process is structured.

Speaker 1:

Delta Dental provides a standardized locum tenens dentist form that needs to be submitted when such coverage is needed. According to Section 2 of the Delta form, and I'm quoting, this form must be completed when a contracted network dentist will be absent from their practice due to death or disability, including maternity leave. The locum tenens dentist may provide care under the treating dentist contract for up to 12 months or until a replacement dentist is named. The form also goes on to clarify that Delta Dental must be notified of the locum tenens arrangement in writing before the temporary provider begins seeing patients. It's also adding the treating dentist contract remains in place during the locum arrangement, provided the locum dentist is appropriately licensed and qualified to treat patients. That's the credentialing part, the vetting part. I'm going to put the link to this form, this document, in the show notes. So if you're interested in reading the entire document, go to the show notes and you can grab a copy of it there. Here's the catch this only applies when the locum dentist is stepping in for a provider who qualifies under the carrier's locum tenants policy. That means the original provider must be out for a covered reason Again death, disability, maternity leave, etc.

Speaker 1:

This workaround does not apply to any of you that are out of network. If you are out of network with a payer, there is no in-network NPI to bill under and there's no locum leeway right. I hope that makes sense. The locum tenens allowance is only useful if the regular dentist is in network and the carrier permits temporary substitution under the contract. If your office is entirely out of network with a payer, you will still bill the treating dentist as is, because you're out of network and obviously your associate would be out of network as well. Because you're out of network and obviously your associate would be out of network as well and the patient's going to be responsible for the full fee, or you're going to balance bill the patient to your full UCR fee. So locum tenens is a valuable tool, but it only works if the foundation is compliant.

Speaker 1:

To begin with, I want to clear up another big misconception. Locum tenens is not a hack or a shortcut. It's a well-defined, regulated solution for keeping your doors open when your main dock can't be in the chair. Locum tenens literally means to hold the place of. To hold the place of. It allows another licensed provider to temporarily treat patients under specific circumstances when the treating dentist is unable to. Some of the covered reasons, as I have previously mentioned are the big three Maternity leave, disability, think like major illness or injury or death of the treating dentist. That's it.

Speaker 1:

You're not allowed to use locum tenens for vacation, sabbaticals, burnout breaks, or because the owner dentist wants to go to Italy for three weeks. It doesn't matter how nice the photos are going to look on Instagram, you're not going to qualify for locum tenants to go to Italy for three weeks. So you know, every insurance company, friends, has their own rules and it's your job to get those in writing. Delta Dental, for example, gives you a very narrow definition of when a locum can be used, and even then only for up to 12 months, or a replacement dentist is named. Other payers might limit locum tenens to 60 days. Either way, you better know the window and file the paperwork before the locum starts seeing patients.

Speaker 1:

So let's talk about some real world examples of locum tenens cases. I know that this all sounds fine in theory, but how does it work when life actually hits your practice? Let's talk about example number one maternity leave. Dr Smith is expecting and plans to take eight weeks off Totally reasonable. Rather than kill the schedule or overload hygiene, the practice brings in Dr Lee to cover. What is your first move Contact every major insurance company Dr Smith is contracted with. Ask in writing if they allow locum coverage for maternity leave. Then submit the required paperwork. Delta has a form, as I mentioned earlier, and others might want a letter or a credential verification. The goal is to keep your claims flowing under Dr Smith's contract so patients stay in network and your billing doesn't crash. Example number two major surgery. Dr Gomez is having back surgery and will be out for 10 weeks. This falls under the disability umbrella. A locum dentist is a perfect fit, but only if you file the documentation and stay within each insurance company's rules. Some insurance companies cut off locum billing at 60 days. Others require special modifiers on the claim. If you're not paying attention, those claims will hit the rejection bin really fast.

Speaker 1:

This is example number three death in the family. This one is the hardest one when we're dealing with locum. Dr Tran's father passes away unexpectedly. She has to leave the country for three weeks and the office brings in a temporary dentist to help out. Here's the problem. This does not qualify for locum coverage. Under most plans, including Delta Dental, the death must be that of the provider, not a relative. That means you can't bill under Dr Tran's NPI and you can't fudge the records and hope it all gets unnoticed. You either need to bill under the temp if they're already credentialed with that payer, bill under the temp if they're already credentialed with that payer.

Speaker 1:

Unpopular opinion reschedule patients or accept out-of-network status and have the patients pay accordingly. I know it's horrible, you guys. I know I hear myself when I say it, but I am talking to you about this because I see this happen all the time and it really blows me away when I'm working with a group. And I'm working with a group that has 15, 20 offices and they're all billing under the main provider's NPI because they intentionally want to avoid the credentialing process credentialing and contracting process of these associates who seem to be on a revolving door status. And it just makes more sense from a timeline perspective and productivity perspective to just bill under the main doctor's NPI and I promise this will not go unnoticed. This will catch up to this group and I see this so often that I was the last time I saw it.

Speaker 1:

I just thought to myself I need to talk about this on the podcast because I don't think people realize that this is insurance fraud. I really don't. I want to believe that we didn't know any better, and now you do. So we're going to try and fix the situation. At least, that's what my hope is.

Speaker 1:

So my message here is don't skip the credentialing process for new associates. You bring in a new doctor, you fill out the credentialing packet and then what? You wait and wait, and somewhere in that wait someone in the office says why don't we just bill under the owner until this doctor is approved? Don't, Just don't. That's all I can say. I know it feels like a big deal. It's a big deal legally, ethically, financially and operationally. It's not just pushing paper, it's compliance. You guys, instead, I want you to have a different plan. I need you to submit credentialing documentation at least 60 to 90 days before that associate's first day, track your submissions and get confirmation emails, make a spreadsheet of every payer and where the associate stands. I like to use mondaycom for credentialing and contracting because it helps us to see where the associate is in that process. Mondaycom is a project management tool and the credentialing and contracting process is a big project, especially as we work with larger groups and we have associates that we are billing for regularly coming in and out of the doors. We are definitely trying to kick off that credentialing process, the first step to getting this associate recognized at our client's location.

Speaker 1:

Collect out-of-network rates if you need to. If this dentist is seeing patients while they are going through the credentialing process say for Delta Dental, you should be collecting your full fee from the patient, whether that's accepting payment from Delta out of network. And let me just pause here and make one quick notation this idea that if you are out of network with Delta they will always send the check to the patient is not true Like that. You guys, we need to debunk that myth because I would say about 60% of the time the check will come to the office and the other 40% it will go to the subscriber, not necessarily to the patient, it goes to the subscriber. So I need all of you to understand that there are a lot of misconceptions, old proof truths that did apply at one point in billing but no longer apply today. I want you to debunk that myth with me, because if you ask a plan specifically I'm talking about Delta If you ask Delta whether or not they accept assignment of benefits when you are verifying or obtaining a breakdown of benefits for a Delta patient, if you ask them up front, you can then know whether or not that check will in fact come to your office. And a lot of times when you ask them, does this plan accept assignment of benefits or translation? Will the check come to our office and they say yes, then you don't have to worry about collecting that treatment in full for that patient, if you choose to do so.

Speaker 1:

Okay, so that I just wanted to take a side note there and let's get back to our regularly scheduled program here Having patients sign acknowledgement forms that they will be seeing an out-of-network provider, so that there's no surprises. You know, we want to stay in compliance with the no Surprise Act and one of the biggies is when a patient finds your office through the Delta Dental Network. Again, I'm just going to continue to use Delta as the example. They find your facility through the Delta Dental pamphlet that they have and they are seen by an associate who's out of network. That is a violation of the no Surprise Act, so we want to be very careful with that. That's a whole other topic that I can talk about. But we as billers friends, we have to stay on the up and up on, you know, state and federal regulations. We have to understand things like credentialing and contracting and how that affects our billing. We have to understand things like locum tenens. There's so much that needs to happen for us to run a proper billing department.

Speaker 1:

Lastly, I just want to urge you to keep airtight documentation. Make sure that everyone on the team has a unique login. Make sure that your clinical notes are signed electronically by the right provider, electronically by the right provider. Make sure that we have accurate scheduling notes. Insurance companies are now wanting to see more and more documentation about how long the patient was scheduled for. Sometimes they're asking for a copy of the schedule, which in my opinion, is going to violate HIPAA for the other patients that are on. So I think just taking a quick screenshot of that particular patient's appointment as it stands on the schedule for that day and then attaching it to the claim is sufficient, rather than screenshotting the entire schedule, because now we're placing other individuals' information on the claim form. But that again, I'm not trying to go down all the rabbit holes. I can, because I love this stuff, but I'm not trying to do that today. So let's talk about my final thoughts and some takeaways for you. This episode was a slight deep dive and, honestly, this is just scratching the surface, but here's what I hope you take away from this episode Credentialing and contracting are not the same.

Speaker 1:

Stop using those terms interchangeably. Two you need both steps completed to be in network. Three billing under someone else's NPI I can't even believe I have to say this. Billing under someone else's NPI I can't even believe I have to say this. Billing under someone else's NPI is never okay.

Speaker 1:

Four locum tenens is powerful but narrow in its scope. You need to use it the right way. Five get everything in writing. No verbal confirmations from insurance companies. We need to make sure that we are getting everything in writing and finally, audit your process regularly. Don't wait for an insurance company to do it for you. So if you have been enlightened and you have learned a couple of things like billing under someone else's NPI is fraud, you might want to take an audit, do an audit and fix that. Okay. So if you made it this far, you're probably the kind of biller or manager who gives a damn, and I respect that. If this hit home for you, forward it to someone who needs it, share it with your team and if you want help setting up credentialing SOPs or auditing your claim trail, check out dentalbillingdonerightcom and set up a meeting. I'd love to talk to you about it. Until the next episode, friends, stay sharp, stay compliant and keep fighting the good fight. I'll see you in the next episode.

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Ericka Aguilar

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