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
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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 andrew. solinger@wallerlaw.com.
DENTIST ENTREPRENEUR ORGANIZATION • MAY/JUNE 2022
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