If you are interested in billing medical insurance for services such as dental sleep medicine, one of the first questions you may ask is: How do I become a credentialed provider?
The answer depends on whether you want to become an in-network provider or simply bill insurance out-of-network. While the terms are often used interchangeably, the processes can be very different.
Out-of-Network: Registration Comes First
Many dentists who bill medical insurance do so as out-of-network providers. However, before submitting claims, it is important to make sure you are properly registered with the insurance company.
Out-of-network registration typically involves providing your professional credentials, tax information, and other required documentation to the payer.
One common mistake is submitting claims before completing this process.
For example, you don’t want to simply start billing Aetna and assume everything will work itself out. A claim may initially appear to be processing, but after weeks or even months of follow-up, you may discover that the insurance company does not have you properly registered in its system.
Taking the time to register with each payer beforehand can help avoid unnecessary claim delays and frustration.
Becoming an In-Network Provider
Becoming an in-network provider is a different process and can require additional time and negotiation.
For dentists who want to participate in an insurance network, the credentialing process generally involves submitting an application and providing information about the individual provider and practice. This may include your NPI information, professional credentials, tax documentation, and other required materials.
Lately, the credentialing process has been taking approximately three to six months, and in some cases, it can take even longer. The timeline depends on the insurance company and may involve significant back-and-forth communication, additional documentation, and contract negotiations.
Another important factor is whether the insurance company is currently accepting new providers into its network. Even if you meet all credentialing requirements, a network may not be open to additional providers in your area.
New Providers May Face Fee Negotiation Challenges
It is also important to understand that becoming credentialed does not necessarily mean you will be able to negotiate your desired reimbursement rates.
Some insurance companies may be unwilling to negotiate fees with a brand-new provider, particularly if you do not yet have an established history of claims or patient volume with that payer. In some cases, you may need to establish yourself within the network before there is an opportunity to revisit contracted fees.
This is one reason it is important to understand the financial implications of joining a network before signing a contract. Being in-network is not automatically the best choice for every dental practice.
Why Consider Becoming In-Network?
While many dentists successfully bill medical insurance as out-of-network providers, there are situations where becoming in-network may make sense.
For example, as your practice grows and your medical billing services become a larger part of your practice, participating in certain insurance networks may provide additional opportunities.
Being in-network may also be beneficial when developing relationships with physicians, as some physicians may prefer referring patients to providers who participate with insurance plans.
However, whether becoming in-network is the right decision depends on your practice, your patient population, and the insurance plans available in your area.
What Is a Gap Exception?
If an insurance plan is not accepting new providers, or if a patient does not have out-of-network benefits, a gap exception may sometimes be an option.
A gap exception can allow a patient to receive care from an out-of-network provider at in-network benefit levels when there are no appropriate in-network providers available within a certain geographic area.
For example, if there is no qualified in-network provider within approximately a 30-mile radius, the patient may be eligible for an exception.
Requirements can vary by insurance plan, so it is important to verify eligibility and obtain approval when necessary.
Can I Complete Credentialing on My Own?
Yes. If you want to pursue credentialing or registration yourself, most insurance companies provide information directly on their websites.
You can typically search for terms such as:
- Provider credentialing
- Join the network
- Become an in-network provider
- Provider registration
- Out-of-network provider registration
The insurance company’s website will generally provide instructions and forms outlining what information is required.
Whether you are registering as an out-of-network provider or applying to join an insurance network, it is important to follow each payer’s specific requirements.
What About Medicare?
Medicare is another important consideration for dentists providing oral appliance therapy for sleep apnea.
To bill Medicare for qualifying sleep appliances, the process is different from traditional medical insurance credentialing. Dentists must meet Medicare requirements to become eligible to provide and bill for these devices, including obtaining the appropriate status as a DME supplier.
The process can take several months. Lately, the timeline has been approximately three to six months, although it can vary depending on the circumstances.
It is also important to note that Medicare does not cover TMJ appliances. Therefore, Medicare enrollment for DME purposes is specifically relevant to qualifying sleep apnea appliances and related coverage requirements.
Credentialing Can Take Time, So Plan Ahead
Whether you are registering as an out-of-network provider, applying to become in-network, or pursuing Medicare DME supplier enrollment, the process can take time.
The key is to avoid waiting until you are ready to submit your first claim.
Start the registration or credentialing process early, gather the necessary documentation, and be prepared for follow-up requests from insurance companies. If you are considering joining a network, also take the time to understand the contracted fees and whether the insurance company is willing to negotiate with a new provider.
With the right preparation, you can avoid unnecessary delays and put your practice in a better position to successfully bill medical insurance.
Need Help With Credentialing?
Navigating insurance credentialing, network participation, and Medicare DME supplier enrollment can be time-consuming and confusing. Getting the right support can help simplify the process and ensure your practice is properly set up before you begin billing.
Nierman Practice Management offers credentialing assistance for dental practices seeking in-network participation and Medicare DME supplier enrollment.