A frequently asked question in the dental industry is whether or not a practice can bill and receive payment as an in-network provider for services provided by a dental associate doctor who is not credentialed with insurance companies the practice participates in. Many doctors are not aware of the billing rules when it comes to submitting claims in this circumstance.

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By Jennifer Blood, CPA – Manager, Doeren Mayhew’s Dental Division 

In fact, one of the most common questions often posed is whether the associate doctor should be credentialed with each insurance company prior to providing services to patients. The answer is typically yes.

The credentialing process can take months before it is finalized which causes issues when onboarding an associate that is not yet credentialed with the payor. Attorney Lisa Lucido with Hall, Render, Killian, Heath & Lyman, PLLC recommends that it is best practice to properly plan in advance of the associate joining the practice to allow enough time for he or she to obtain credentialing before providing services to patients. However, the delay in credentialing and the need to provide patient care often causes operational challenges for many dental practices. These issues may be potentially resolved if the payor has adopted the Medicare “incident-to” billing rule. That is, if the payor allows a non-credentialed provider to perform services under the supervision of a credentialed provider. In that case, those services may be billed on an “incident-to” basis under the NPI of the supervising, credentialed provider.

It is important to note not all commercial payors follow the Medicare “incident-to” billing rule. Many commercial payors specifically prohibit this practice even if a credentialed provider is providing supervision. This makes it critical to understand each insurance company’s rules. Typically, if the dentist is a non-credentialed, non-participating provider, then the insurance company will not reimburse for their services.

There is some compliance risk associated with this billing practice. It’s recommended you review your practice’s commercial payor contracts and policies on an individual basis before billing for the services of the non-credentialed provider. Seeking out legal counsel can also help avoid any unforeseen risks associated with this billing practice. Doeren Mayhew’s Dental Division partners with health care attorneys to assist clients with matters such as this. If you’re looking for more information on non-credentialed insurance billing practices, contact our dental cpas and we can help put you in contact with right legal professionals to mitigate related risks in your practice.

*This article is for informational purposes only and should not be construed as legal advice.