Creating a Better Credentialing

Process with CAP Plus

By Shelley DeGroff, Founder of PPO Advisors

When I was working as an office manager for dental practices, one of my responsibilities was credentialing. Like most dental office managers, I discovered that credentialing can be a real hassle. Unfortunately, it’s only gotten worse since then! Credentialing eats up a ton of staff time, requires a lot of paperwork, and it’s easy to miss critical deadlines. Any little hiccup in the process can create delays that often prove costly to a dental practice.

A Better Credentialing Process

Because of my experience as a dental practice office manager, one of my priorities when I started PPO Advisors was to find a way to streamline and simplify credentialing. We did it by creating a program called Credentialing Access Point (CAP) which practices can use on their own or opt for additional support with CAP Plus.

Our CAP Plus service has two important objectives: provide an efficient and accurate system to manage the entire credentialing process while minimizing the amount of staff time. CAP Plus also takes advantage of the opportunity credentialing provides to get higher reimbursements from insurers. CAP Plus is one of PPO Advisors most valuable tools in our fight to create a level playing field for dentists where they deal with insurance companies.

What is Credentialing?

Credentialing is a process each provider, or dentist, needs to complete to be eligible for participation in various networks with insurance companies. Insurers control the process which requires providers to submit detailed paperwork with proof of a dentists education, residency, training, work history, licenses, etc. Dentists must be credentialed and then re-credentialed with each insurer every 2-3 years, depending on the contract. Missing the deadline for re-credentialing can have a serious impact on revenue.

Credentialing Delays are Costly

When your dental practice brings on a new associate, they must become credentialed by the insurance company before they are considered part of the PPO network. Until then, all the patients the associate sees must be treated as out-of-network, which is a huge headache for the practice and not exactly popular with patients. If there are any errors or missing information on a credentialing application, it will take longer to get approved, extending the time until an associate can treat patients in-network. Mistakes are often inevitable because credentialing is a time-consuming process handled by busy office managers.

CAQH Stores Data – Not a Source for Credentialing

The Council for Affordable Quality Healthcare® (CAQH) is an online repository of credentialing data. Practitioners self-report demographic, education and training, work history, malpractice history, and other relevant credentialing information for insurance companies to access. CAQH is a repository for information, but it’s a cumbersome system and not meant to be a source for re-credentialing.

How Insurers Use Credentialing to Their Advantage

Insurers want to keep fees low, and they understand that credentialing is an opportunity for providers to try and increase their fee schedule. A complex credentialing process helps insurers by keeping providers focused on paperwork, not the terms of their agreement. If an insurance company can keep recredentialing a provider without having to increase their fees, that’s a win for them.

CAP Gives Providers a One-Stop-Shop for Credentialing

CAP is proprietary software developed by PPO Advisors that gives dental practices an extremely efficient way to manage the entire credentialing process:

  • Licenses
  • Fee schedules
  • Re-credentialing dates
  • Entire dental team
  • Multiple locations
  • Deadline reminders
  • CAP tool support
  • Re-credentialing applications
  • Ongoing support

If your practice has staff turnover or someone’s role changes, CAP is the one place everybody can reference to find information about the provider’s credentials, their applications, their fee schedules with insurance companies. Everything is in one place.

CAP Plus Leverages Credentialing Process to increase Fee Schedule

With CAP Plus, our PPO Advisors team handles the entire process for you by tracking all the deadlines, managing the paperwork, and providing reminder systems for licenses. In other words, we handle anything that is related to credentialing and required to keep a provider in good standing with insurers. CAP Plus can be especially helpful for DSOs or multi-location providers where there’s multiple layers of credentialing fee schedules to keep track of.

Strategic Approach to Credentialing

A key value of CAP Plus is our strategic approach to credentialing. In addition to managing all the paperwork, we look for better ways to be credentialed, which includes evaluating your current agreements to determine whether or not it’s the best deal for a new associate. In doing so, we look at your options to see if the best path to higher fee schedules is through a direct contract or third party agreements. Depending on the situation, we may opt to renegotiate an agreement, or we may choose to intentionally fall out of network and pick up the insurer through a different avenue.

Yes, it’s complicated, but we understand how the system works and we use our knowledge to help dental providers get a better deal from insurers.

If you have questions about credentialing or how CAP Plus could benefit your practice, contact PPO Advisors. We’ve successfully completed over 12,000 credentialing applications and we’re prepared to help manage the process for you.

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