Difficulties in Credentialing

Links Mentioned in This Episode: PPO Advisors blog, “Case Study Shows 21% Fee Schedule increase after renegotiating PPO Contract”:

Main Takeaways:

✅ Credentialing is no longer a simple process.
✅ Understand why it’s important to get credentialed.
✅ Consider going fee-for-service and PPO in a hybrid model.
✅ Don’t go in-network with every insurance or the wrong insurance.
✅ Understand the stacking order and the Most-Favored Nations clause.
✅ Steer clear of NPI fraud! You will be caught, with heavy consequences.

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1. Why is Credentialing Essential in Today’s Dental Practice Landscape?

Credentialing has emerged as a cornerstone in modern dental practice management, primarily due to patient preferences and insurance landscape dynamics. The trend has shifted significantly, with an increasing number of patients covered by insurance seeking care exclusively from in-network providers. This change underpins dental practices’ need to undergo the credentialing process with various PPO insurance companies, ensuring they are recognized as preferred providers. Credentialing broadens a practice’s potential patient base and aligns with the strategic goal of enhancing PPO profits by tapping into the vast network of insured patients seeking quality dental care.

The journey from a mere 7% to an impressive 18-19% of practices operating on a fee-for-service model over recent years highlights a broader industry shift towards more flexible and patient-centric service models. Despite this positive trend, the reality remains that a large segment of the population still relies on insurance plans, making credentialing an indispensable strategy for practices aiming to serve a wider community. However, becoming an in-network provider is fraught with challenges, including navigating complex agreements and meeting stringent requirements set forth by insurance companies. The ultimate goal is to ensure practices are well-positioned to deliver exceptional care to insured patients, fostering a profitable and sustainable business model that leverages the benefits of PPO consulting and strategic dental PPO negotiation.

2. How Has COVID-19 Impacted the Credentialing Process and PPO Profits?

The onset of the COVID-19 pandemic served as a pivotal moment for dental practices worldwide, prompting a deep dive into insurance contracts’ financial and operational impacts on their business models. The temporary closure of practices provided a unique opportunity for providers to evaluate their participation in various PPO plans, examining the balance between the administrative burden of credentialing and the financial rewards of being an in-network provider. This introspection led to a discernible shift towards dropping less profitable or overly burdensome PPO plans, favoring a more targeted approach emphasizing profitability and efficiency.

The pandemic highlighted the importance of financial resilience and operational flexibility, driving practices towards a hybrid model that combines the stability of fee-for-service arrangements with the broad patient base afforded by selective PPO plan participation. This shift is indicative of a broader trend towards optimizing PPO profits through strategic decision-making, leveraging insights from PPO consulting to navigate the complex landscape of insurance contracts. The evolution from a near-universal reliance on insurance plans to a more nuanced, strategic engagement with PPO insurance companies reflects a maturation of the industry’s approach to financial management and patient care in the post-pandemic era.

3. What Are the Challenges and Timeframes Involved in the Credentialing Process?

While critical for dental practices aiming to expand their patient base and enhance their profitability through PPO networks, the credentialing process presents a complex and often time-consuming challenge. Providers embarking on this journey must prepare for a meticulous verification process conducted by insurance companies to assess their qualifications, practice standards, and eligibility to join as in-network providers. This process, which can extend up to six months or more for new graduates awaiting licensure, involves a comprehensive review of credentials, malpractice history, and other critical factors that underpin the provider’s suitability for inclusion in an insurance network.

The extended timeframe for credentialing, particularly for new providers or those undergoing recredentialing, underscores the importance of early and proactive engagement with the process. Dental practices must navigate this timeline strategically, balancing the need to expand their in-network offerings with the operational realities of managing patient care and business growth during the interim. The complexities of the credentialing process, coupled with the strategic implications of selecting the right PPO plans to participate in, highlight the value of expert guidance in PPO consulting and dental PPO negotiation. Providers can make informed decisions that align with their long-term business goals by understanding the intricacies of the process and the impact of various insurance networks on practice profitability.

4. Can You Elaborate on the Risks of NPI Fraud in Credentialing?

The credentialing process, integral to establishing trust and legitimacy within the PPO network, also exposes providers to NPI (National Provider Identifier) fraud risk. This form of fraud, wherein claims are submitted under the identity of a provider who did not perform the service, not only undermines the integrity of the healthcare system but also attracts severe legal repercussions. Armed with sophisticated data analysis tools, insurance companies are adept at identifying discrepancies in claim patterns, which can trigger audits and investigations leading to fines, criminal charges, and potentially the loss of the ability to practice.

The implications of NPI fraud extend beyond individual providers, affecting the reputation and financial stability of practices involved. It underscores the critical importance of ethical practice management and adherence to legal and regulatory standards in all aspects of insurance billing and credentialing. The potential consequences of NPI fraud are a stark reminder of the need for vigilance and integrity in the management of insurance relations, reinforcing the value of expert advice and support in navigating the complex landscape of PPO consulting and credentialing.

5. How Should Practices Approach Insurance Networks and Negotiations for a Profitable PPO Strategy?

Developing a profitable PPO strategy requires a nuanced approach to insurance network participation and contract negotiation. Practices must thoroughly analyze their patient demographics, market dynamics, and the alignment of various insurance plans with their business goals. This strategic evaluation should inform the selection of PPO plans, prioritizing those that offer favorable terms, sustainable reimbursement rates, and the potential for productive negotiations over time.

Optimizing PPO profits involves the initial selection and credentialing process and ongoing engagement with insurance companies to renegotiate terms and adapt to changing market conditions. Practices should leverage PPO consulting services to gain insights into industry trends, benchmarking data, and negotiation tactics that can enhance their position in contract discussions. By adopting a proactive and informed approach to PPO participation, dental practices can navigate the complexities of insurance networks, securing contracts that support their long-term profitability and growth objectives. This entire article is perfect. No changes.

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“Why do we credential? Well, we credential because most of our patients that we see anymore have insurance and they want to go to an in-network provider. The statistics are changing though. It used to be where there was only seven percent fee-for-service the last couple two years. That statistic has changed and we’re growing to see more and more fee-for-service, which is great. I like seeing that. The latest statistic is around like 18, 19% fee-for-service practices back into the U.S. But still, we have a ton of providers graduating out every year, and there are more and more providers building their own practices, joining as associates, and they need to be busy. And so, the “why” there is getting in-network with insurances and credentialing and becoming an in-network provider.” (2:20—3:08)

“Becoming a credentialed provider, it’s a process. It’s a process that has gotten increasingly difficult over the years. They don’t make it easy. They don’t want it to be easy. But they do want you to be in-network, and they really push for providers to be in-network and for patients to go to in-network providers. Now, the insurance companies send their EOBs out to the patients with, ‘If you would’ve gone to an in-network provider, your savings would have been X. Here’s a list of five providers in your zip code.’ They’re promoting in-network. So, it is really hard to stay fee-for-service or to not go in-network. But we certainly don’t want people to go in-network with the wrong insurances just out of fear either.” (3:11—3:49)

“My personal hypothesis [for why fee-for-service increased from seven to 18%] is COVID-19. Right before COVID-19, we were seeing seven percent. Now, it’s 18%. So, that gave providers time to look at how insurance was impacting their practice when they were shut down. They were looking at contracts. They were looking at their dollar values and saying, ‘This isn’t working.’ And a lot of providers started to drop.” (4:19—4:43)

“I really see more of a hybrid. I think we’re not going to see that full-on fee-for-service structure just blow up, but a hybrid of dropping lots of PPO plans that are not working for practices and keeping just a very few in-network policies. I think that’s the new way that everybody is going to start to trend.” (4:52—5:12)

“[The credentialing process] takes a long time, much longer than what you’re going to anticipate as a provider. So, associates that are graduating this month, most providers that are getting ready to graduate, they’re not going to actually get their license until June or July. They can’t even start the credentialing process until they have a license. And that means, from there, it’s going to take an additional, with the insurance companies, 30 to up to 120 days — 30 days at best, which we rarely see a contract go through in 30 days. That’s not normal, especially for a brand-new provider.” (5:21—6:00)

“When you go through the credentialing process, they are verifying that you don’t have malpractice, that you truly do exist, that you have a dental license, and there’s nothing risky about you as a provider being in their network. So, the vetting process that first time definitely takes a lot longer than your second go around with either a recredential or going back into network after deciding to have termed maybe several years ago. So, new providers, they really need to expect, especially if they’re going with umbrella companies or third-party contracts, that process always takes about six months. That’s the number I’m going to give you.” (6:00—6:42)

“[Submitting claims under someone else is] very dangerous — NPI fraud. So, right there, you’re committing NPI fraud. NPI fraud is identity fraud. It’s a fraud where you are saying, ‘I’m a provider of service, and this is my claim that I am submitting as the provider of service who did all the work,’ when you weren’t that provider. So, now, the insurance companies who you know data mine every single thing you submit — they know how many claims, on average, a provider is submitting in, the types of procedures that they typically do on a daily basis — they have an idea of exactly how this practice functions. And then, all of a sudden, all of that doubles because the provider is now submitting claims in as the associate as well. They find that out immediately. And that is when they start digging in, red flagging the practice, and start to look at things.” (7:09—8:02)

“Most practices get caught on NPI fraud through a Medicare of a Medicaid audit first. And then, it explodes from there. So, those RAC audits that the Medicare and Medicaid sent out, that’s where those get caught. And so, when you are doing NPI fraud, identity fraud, and you’re defrauding the government, they like to make a case out of you and scare everybody else. So, it’s definitely something you want to stay away from. It’s very easy to catch NPI fraud.” (8:03—8:36)

“I see [NPI fraud] a lot. I hate to uncover that, but I see it a lot. There are small cases where we’ve had instances where an associate has been submitting under an owning doctor for a little bit, and an insurance company catches it — because you know what the insurance companies are doing. They’re trying to recruit providers. So, they’re looking at directories on websites and saying, ‘Well, I don’t have that doctor on our register. Why is it listed on their website?’ And so, then they’re calling, and they’re saying, ‘Hey, do you have more providers than just doctor so-and-so?’ And in those cases, when a recruiter is trying to find doctors to get their quotas, and they use that to their advantage, let it slide, get them credentialed, and will just forget that that ever happened. Unfortunately, that’s how the system works. There are other cases where the [NPI] fraud is so big, it was caught by a RAC audit first, that these providers are basing prison time, fines that they can’t recover from, loss of license, forever. There are some big red flags that go with this. So, we certainly don’t want to encourage providers to even play with the idea of it.” (8:46—9:59)

“For those new providers coming out of school, no, [there’s not a lot you can do until the credentialing process is complete] because they don’t have a license. So, there’s nothing that can be submitted until the license is in. But for providers that are switching associateships and they’ve been credentialed in the past — no. I mean, it’s still going to take time to get them credentialed. It may not take as long, but they can at least start the process significantly sooner. So as soon as a letter of intent is signed with an associate that has all of their credentials, their license, their DEA, all of the things that are needed, then the credentialing process can start. So, even if that contract for the associate doesn’t start for 90 days down the road, still start credentialing them so that that timeframe is narrowed down.” (10:12—10:58)

“The other thing is, providers can see patients as out-of-network. There’s that thought of, ‘Well, for out-of-network, we just can’t see anybody. They can only see the fee-for-service patients,’ and that’s not true. They can see patients that are in-network as an out-of-network provider. Out-of-network benefits will be utilized, and you can give insurance patients a discount so long as the discount is shared with the insurance company. So, you can put on the claim form that we’re providing a 10%, 20% discount to the insurance patient to offset that out-of-network benefit that they’re utilizing. So, there are ways to work with patients so that they understand that, ‘Hey, this is what’s going on,’ and the practice is taking care of the additional out-of-pocket expense that they’re taking on to be seen as an out-of-network patient.” (10:59—11:53)

“There are so many plans out there, and it’s overwhelming. This fear of, ‘We need to be in-network with everybody so that we can gain as many patients,’ is really not what I want our clients to be doing. I want our clients to credential with what is necessary for their demographic to be successful long-term. Meaning, looking at insurance companies that negotiate, insurance companies that have a record of increases annually, or at least every two years, that are substantial enough to keep you at a sustainable rate. This going in-network with everything because one patient asked for you to be in-network sometimes doesn’t make sense.” (12:03—12:44)

“There’s a connection between all of the insurance companies. They’re all connected one way or another. So, when a provider says, ‘Well, yeah, I’ll go in-network with your insurance companies,’ you may also be going in-network with six, seven, 20, 30 other insurance companies from that one agreement. And that’s where then you start to really fall into the cycle of, ‘Now, we’re in-network with everything. We don’t know where it’s coming from. The fees are getting out of control, and you start to feel overwhelmed. So, we don’t want providers to just blindly decide, ‘This is who we’re going in-network with.’ There needs to be a “why”. Why am I going in-network with this insurance company? There are X amount of employers that have this insurance company in my area.’ Typically, you want the city’s insurance. You want school’s insurance. You want the hospital’s. Typically, the fire department’s and the police department’s fall under the city. So, those big employer groups, look into those in your demographic. Know who their insurance is with and start there. And then, figure out those contracts, ‘What else am I getting from those?’ before we start this spiral of accepting everything.” (12:45—13:58)

“The insurance companies should give you a payer list when you sign up to be in-network with them. So, when you sign up with Guardian, they send you a fee schedule and their payer list, all of the other insurances you get, but being in-network with them. So, on a yearly basis, you should be asking for the payer list from the insurance company so you have an idea of what new networks have come into play, which ones may have fallen off. And that’s with every insurance company. So, all insurance companies have a payer list. Most of them don’t give them out unless you’re asking for it. So, it’s super important to have a copy of those.” (14:16—14:56)

“[Look] at your EOB to verify how the claim was paid. And that goes back into when I talked about the Most-Favored Nations clause. I don’t know if you remember that last quarter, but the Most-Favored Nations clause is what gets every office without them even knowing. It’s where these insurance networks that are all connected — they’re all connected one way or another. Aetna shares to Guardian. Guardian shares to Principal. Principal shares to Ameritas. It’s all one big web. So, once you sign an agreement with one and it’s shared to another, they have the ability to default to the lowest fee schedule in your practice. So, if you’re not stacking your contracts and making sure they’re paying off of the fee schedule you want, it’s an uphill battle. You’re never going to get ahead.” (14:57—15:46)

“The Most-Favored Nations clause, it’s huge. It really covers everything. It is an agreement that allows other shared agreements within one agreement to share their information, and fee schedules, in dental. So, that’s how it all comes into play for us. But a lot of people don’t think Most-Favored Nations clause even applies to dental. ‘That’s a government thing. That has something to do with something bigger than us.’ And no, that’s not the case.” (16:07—16:35)

“There are so many ways to contract. We have direct contracts, which are going to be directly going with that company. So, that’s me as a provider directly going to Aetna and saying, ‘I want to be in-network with you, with you directly,’ and Aetna says, ‘Here’s my contract. Here’s the agreement. You’ll be credentialed with us in 10 weeks.’ Or as a provider, I can go to Connection Dental. And it’s one of the largest umbrella companies or third-party administrators, so you’ll hear TPAs used a lot. You can go to Connection and say, ‘I want to be in-network with Connection.’ And through Connection, I’m going to grab Aetna, Ameritas, Principal, UnitedHealthcare, Guardian, and on down the line. So, now, I’m in-network with multiple insurances through one contract, one fee schedule. And there are so many ways you can use that to your advantage, but there are so many ways that it hurts a practice because they don’t understand the stacking order and that Most-Favored Nations clause coming into effect.” (17:04—18:07)

“When a provider goes in-network with Aetna and Guardian and Connection, now there are three ways Aetna can be picked up. It’s picked up directly, it’s picked up through Guardian, it’s picked up through Connection. So, now, Aetna is going to look at all of those agreements and see which one is going to pay less. So, even though they’ve got a really good fee schedule negotiated with Aetna when they originally signed up, Guardian may be less, and so they’re going to pay those claims that way. So, it’s figuring out, ‘Wait, I’m over-credentialing. I’m already in-network with so many plans. Maybe I shouldn’t be picking up this contract because it’s going to override a different contract.” (18:07—18:49)

“Unfortunately, that’s a double-edged sword. We can go direct for a lot of good reasons. Some of the direct contracts have incentive plans. Some of the direct contracts — they’re always going to credential faster than a third party. So, a lot of providers that are going through acquisitions or are in a huge hurry to get credentialed, they feel going direct is a better route because it’s significantly less credentialing time. But on the flip side of that, their fees, directly, are typically not as competitive as third-party fees. Now, that’s not always the case. Every demographic is different. So, a provider who’s going to do their own credentialing really needs to know how they can pick up each insurance company so that they’re looking at all of their options and deciding from there, ‘This is how I’m going to credential. I’m going to credential with these six companies through this one third-party contract, and then I’m going to go direct with MetLife, and I’m going to go direct with Humana,’ because they don’t pick up through the third party or their direct contracts are better contracts.” (19:11—20:21)

“A direct contract sometimes traps a provider. So, it used to be you can get out of a contract whenever you wanted. You still can. You can still term a contract. It takes 90 days to term a direct contract. But these direct contracts are now putting stipulations in where if you term them directly, it’s at their discretion to put a block from you getting picked up through a third party if they want to put that block in place. And so, now, it’s not as black-and-white as it used to be. It used to be a no-brainer. I can term whenever I want. I can readjust this contract over here. Now, we have to really look at the big picture to make sure — that door may not open down the road. So, I wouldn’t risk contracting direct because of the way their clause is written. I would go indirect for that purpose. So, those are the things that we look at when we’re credentialing a client.” (20:38—21:33)

“I think the idea was, five years ago, as a young provider, ‘I’ve got to be in-network with everything in order to build my practice up as quick as possible to catch up to the guys or gals that have been doing this for a lot of years and be competitive.’ Now, we’ve really got to look at what that write-off looks like first. The national average write-off is 45%. That’s a big write-off. And overhead costs have jumped. It used to be 67%. Now, it’s 74%. That’s a big jump. So, as a new dentist, a young dentist, with overhead as high as it is and write-offs as high as they are, honestly, needing to be that hybrid doctor where we’re fee-for-service for some of these big players because it just doesn’t pay to take that 50% write-off is actually going to help you become a better sustaining practice than just accepting every insurance company.” (22:21—23:18)

“We see the trend changing. It went from seven percent fee-for-service and it’s jumped all the way to 18% in the last couple of years. So, I do feel like that number is going to continue to grow. But I’m going to see it grow, hopefully, more in a hybrid model where providers that have been heavy PPO starting to come in and drop a lot of their insurances that just don’t make financial sense for the practice anymore. And then, we can strategically make the plan of, ‘These are the insurances that need to go. These are the ones we keep,’ looking at the ones that will continue to negotiate over the next couple years that will allow them to get out of contracts. All of those will go into play here. And then, as they continue to drop a few, you’ll continue to do that over the course of several years, and then maybe hit that fee-for-service model. But it’s not something you want to jump into, in my opinion.” (23:19—24:11)

“[Forty-five percent in write-offs] means that you have a full-fee service. So, your full fee, your master fee for your practice, is $100 for a prophy. Obviously, I’m just throwing out easy math here. One-hundred dollars for a prophy. But if the write-off level is 45%, that means you’re only paid nearly half of that. You are writing off half of what you do at 45%.” (24:46—25:13)

“Everything is going up. Employee costs are going up. Have you been on Facebook threads, all these threads of, ‘Front office came

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