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Set Up Your Dental Practice for Success

Set Up Your Dental Practice for Success
by Davy Clay

Since insurance is anything but straightforward, there are three things you don’t want to forget as you set up your dental practice for insurance success. When starting a practice or opening a new location, many doctors and office managers have a ton of logistics to tackle, but the details regarding how to get started with insurance and where to learn about claims can seem convoluted and insurmountable.

Setting up a new associate, or a new office, whether it’s a new location or an entirely new practice, can be intimidating. Correct steps must be taken to ensure proper payment from insurance companies that require proper setup and properly trained personnel to send the correct credentialing files, in a timely manner, to the Provider Relations departments at each insurance. Some insurance require certain steps even if you decide NOT to be a PPO provider for them! 

1. DO I GO IN-NETWORK OR STAY OUT OF NETWORK?

This is the main question. The BIGGEST question in fact that a dentist will face when you set up your dental practice. Most practices are looking at the three current philosophies: the old school way, the new school way, and the DSO way.

THE OLD SCHOOL WAY
Most dentists who consider themselves “old school” don’t want anything to do with PPOs. They are FFS (Fee for Service) only. In this scenario, the office will either file the insurance for the patient or have the patient file it themselves.

THE NEW SCHOOL WAY
Most younger dentists believe going “In Network” with a PPO is their marketing. New patients will find a local dentist through their insurance’s list of in-network providers. Getting new patients is how you become profitable, right? In this example, the philosophy is more volume equals more money. This isn’t always the case because you may be accepting too many insurances with too low fees. As a result, there are a lot of numbers to crunch here. In general, a dentist that is in-network with ALL insurances with a full schedule is making 40% less than a comparable dentist that is only in-network with a few insurances and still has cash-paying patients.

THE DSO WAY
Accept everything you can, it’s all about new patients! No plan left behind! Insurance, Medicaid, CMO, HMO, or Discount Plan – whatever you have, we'll take it! 
 
2. DO YOUR RESEARCH BEFORE CREDENTIALING

The most overlooked process most offices make is credentialing. It may seem simple that you chose to be in network with X, Y, and Z insurance companies – you filled out the paperwork, sent it in, got accepted. They sent you a fee schedule and you entered it in the software. Well, it’s not that easy. Credentialing is like the fine print of the fine print. You MUST research before signing your name to a contract! Research employers in your area, what insurance will most of your patients have? If only 3% of the patients in the city/county have “X” insurance, do we really NEED to be in that network? If “Y” insurance company fees cause you to work for lower than minimum wage, do we really WANT to be in their network? If we really like “Z” insurance fees and most of our patients have it, are we automatically in?

CREDENTIALING
The biggest problem I see regularly with credentialing is:

1. time
2. you signed up for more than you bargained for and had no idea that these are called “Umbrella Networks.” 

• United Healthcare being paid under Guardian fees.
• Carefirst being paid under GRIDPLUS network
• Standard being paid under Connection Dental 
• BCBS of IL being paid under United Concordia

3. BILLING SETUP ON CLAIMS

Claim form set up is one of the most important things an office can do to get claims paid correctly. Having the claim form setup incorrectly can and will cause major issue that will occur when a new associate or a new location is added to the practice. In some cases, the setup has been incorrect for years and insurance companies are actually paying associates instead of the business, all under the wrong NPI 1 instead of having a proper NPI 2. 

• An NPI 1 is given to each provider
• An NPI 2 is for the billing entity

Insurance companies should have the correct information from the start because any change that needs to be made could take months to fix, and you could be missing out on thousands of dollars by setting up your billing and claims incorrectly. Claims should also being showing your Usual and Customary fees on the claim forms you are sending out. Do your own research or consider hiring an expert will save you time and money in the long run.



Davy Clay is an Expert Dental Billing Consultant with 10-plus years experience working in the dental billing and dental insurance industry. His passion is helping dentists and their staff to realize and change the inefficient, inexperienced, and sometimes illegal billing practices taking place within dental practices. With an Insurance degree from University of Georgia and MBA from Georgia Southern University, Davy started Dental ClaimSupport in 2012 after working for Howard Family Dental as the Head of the Billing Department running the billing for their eight practices. Davy is also the creator and moderator for a Facebook Group entitled “Dental Billing Support Group,” and you can also check out his Podcast on iTunes entitled “Dental Billing Support Podcast.”