Rules and Regulations

Why a credentialing backlog can lead to compliance troubles for new dentists.

By Andrew Solinger

Imagine this all-too-common scenario: A new dentist joins your practice – whether from out-of-state, residency, or another practice. Your practice is contracted with a multitude of payors including Medicare, Medicaid, TRICARE, managed care organizations (MCOs) that administer some of these programs, and various commercial payors. Your practice is already busy, and you want your new dentist to start seeing patients immediately. Before you can bill any of these payors, the dentist needs to be credentialed and enrolled with each of them. It’s a time-consuming and convoluted process, different for each payor and full of many hurry-up-and-wait moments. 

Dentists, like other healthcare providers, must be credentialed by their respective payors in order to bill for the services they provide. Some applicants are waiting 30 days to as much as a year for MCOs and other payors to verify documentation, review applications, and make approval decisions. Unfortunately, this growing backlog for government and private payors can lead to the temptation to cut corners when submitting claims during the gap between application submission and approval, but by doing so they may ultimately create significant civil, and possibly criminal, liability.

How can a practice bill for a new dentist’s services after a credentialing application is submitted but before it has been approved? There is risk when a practice bills for services rendered during that period because the application could ultimately be denied. Any claims submitted by the still-un-credentialed dentist may either be denied or, if already paid, may lead to overpayments. If such claims are submitted to government healthcare programs, there is the added risk that they may result in false claims or “reverse false claims” if the provider retains any overpayments.

Some practices opt to hold claims for services rendered by new dentists. Then, once credentials are approved and retroactively applied, the practice submits all claims for services provided during the gap period. This can delay payment, especially for payors with lagging credentialing processes, but it is the safest way to bill for new dentists. 

Most payors – including federal healthcare programs, MCOs, and commercial payors – retroactively approve providers’ credentials back to the date of application. This presumes, however, that the application is ultimately approved, and that the provider complies with all other requirements set forth by the payors. If a credentialing application is denied for any reason, whether it’s incomplete data, failure to meet the payor’s standards, or on any other basis, a new application must be submitted, and the retroactive approval date will typically be the new application date. This means that the period between the first application and the application denial is lost for purposes of submitting claims, and any claims submitted by that new dentist during that period run the risk of either being denied or resulting in potential overpayments.

Regardless of how a practice decides to handle new providers’ claims, it is imperative to understand each payor’s rules and regulations. Medicaid payors have increased their focus in this area. If a practice participates in government healthcare programs, additional attention must be paid to ensure that all claims are accurate and submitted for properly credentialed providers. Buyers considering the purchase of a dental practice or practice management company would be wise to verify that no claims have been billed for non-enrolled/non-credentialed providers under another provider’s number. Failure to exercise due care in this area can lead to significant liability.

Andrew Solinger is an associate at Waller where he assists clients in responding to investigations, audits and other inquiries brought by federal and state government agencies and regulators. He can be reached at (615) 850-8062, or [email protected].