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Friday, September 29th, 2023 | by Kevin Cooper, M.B.A.

Understanding Insurance Credentialing in Dental Practice Transitions


The Role of Insurance Credentialing in Dental Practice Transitions

Insurance credentialing is a ‘necessary evil’ in many, if not most, dental practice transactions today. While some dental practices are Fee for Service only, many participate with Preferred Provider Organizations (PPOs).

It is important to understand why insurance credentialing is necessary, what issues may be encountered during the process, and what can be done in the event a practice sale closes prior to the new owner becoming credentialed with all plans that the practice participates with.

We’ll explore insurance credentialing in dental practice transitions, the insurance credentialing process, potential challenges, and strategic solutions that can help streamline this essential aspect of dental practice ownership.


Understanding Insurance Credentialing

First, what is insurance credentialing and why is it needed? Insurance credentialing plays a vital role in the world of dentistry, ensuring that dental practices can effectively work with insurance companies. It is a process that involves verifying and validating a dentist’s qualifications, licensure status, and compliance with insurance company requirements.

Through credentialing, dentists establish contractual agreements with dental insurance companies, allowing them to be reimbursed for services provided to a patient.

For dental practices, insurance credentialing opens doors to a broader patient demographic. A significant number of individuals seek dental care using insurance coverage, and becoming credentialed broadens a practice’s access to this patient base.


The Importance of Dental Practice Insurance Credentialing From the Patient’s Perspective

For patients, having access to a dentist who is credentialed is important because they may have less out-of-pocket costs by seeing a dentist who is in a network. Importance of Dental Practice Insurance Credentialing

Additionally, being credentialed helps patients make informed decisions when choosing a dental provider by providing them with valuable information regarding a dentist’s qualifications and professional history on their insurer’s website.


Navigating Common Insurance Credentialing Challenges for Buyers

A few issues that can arise during insurance credentialing that buyers should be aware of:

You are Credentialed at a Specific Address

First, you may be credentialed by one or more plans in an office where you are currently employed.

Unfortunately, you cannot transfer or be credentialed automatically at a second location. You are credentialed for a specific location, and any additional location you want to practice and participate in with PPOs will require you to go through the credentialing process again.

The Process Can Take 30-90 Days to Complete

A second issue, and often one of the biggest complaints we hear, is how long the insurance credentialing process takes from start to finish. This, in most cases, can take anywhere from 30-90 days. This is obviously less than ideal, especially when you are trying to nail down a firm closing date when purchasing a practice. Some potential workarounds to address this issue are covered later in this article.

You May Risk Keeping the Dental Practice Transition Process Confidential

A third issue that comes up when working through the insurance credentialing process involves mail from the insurance company being sent directly to the office in the buyer’s name. In most cases, staff in the office are not made aware of the practice being sold until right around closing.

Ideally, the buyer will start the insurance credentialing process soon after the initial offer is accepted and while the Asset Purchase Agreement and other documents are being drawn up.

The dental insurance companies may send some correspondence to the office mailing address, which means that if anyone other than the seller or someone who knows what is going on gets the mail daily, they run the risk of noticing a different doctor’s name, and that could raise questions.

There are various ways to address this, one being, if the staff asks who the doctor is, simply say that an associate may be coming in to assist because the owner may have to be out for a short time for a medical procedure.

Insurance Credentialing

Partner with Insurance Credentialing Companies That Work on Your Behalf

One way to help try and mitigate the time issue up front is to work with a company that specializes in dental insurance credentialing and PPO negotiations. This is often a good option as they will submit the applications to insurance companies on your behalf and will manage the process.

Some will also review your reimbursement rates annually and help you negotiate a better fee schedule. A quick Google search will bring up regional and national firms that assist with this, and there have been many discussions on Dentaltown as well.


What if the Insurance Credentialing Process isn’t Complete After Closing?

If insurance credentialing cannot be completed prior to closing, there are a few ways that treatment can still legally be billed to the insurance provider.

Option 1: Buyer-submitted Claims

One is that the buyer submits claims under the previous owner but lists themselves as the providing doctor. This will result in being reimbursed at an out-of-network rate, but still allows the patient to receive treatment.

Option 2: Put Treatments on Hold

Another option is to put any non-emergency treatment on hold and have those patients wait until credentialing is complete.

Finally, if the selling doctor is to remain working in the practice for a period of time, they could continue to treat patients and submit claims to the insurance company until the buyer is fully credentialed.


Insurance Credentialing Done the Right Way: Key Takeaways

Insurance credentialing is an issue that must be considered early in the dental practice transition process. By partnering with experts and proactively addressing credentialing c