578: Difficulties in Credentialing - Shelley DeGroff - a podcast by ACT Dental

from 2023-05-19T03:00

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Difficulties in Credentialing

Episode #578 with Shelley DeGroff

Episode Resources:


Links Mentioned in This Episode:

PPO Advisors blog, “Case Study Shows 21% Fee Schedule increase after renegotiating PPO Contract”: https://ppoadvisors.com/case-study-shows-21-fee-schedule-increase-after-renegotiating-ppo-contract

Main Takeaways:

Credentialing is no longer a simple process.

Understand why it’s important to get credentialed.

Consider going fee-for-service and PPO in a hybrid model.

Don't go in-network with every insurance or the wrong insurance.

Understand the stacking order and the Most-Favored Nations clause.

Steer clear of NPI fraud! You will be caught, with heavy consequences.

Quotes:

“Why do we credential? Well, we credential because most of our patients that we see anymore have insurance and they want to go to an in-network provider. The statistics are changing though. It used to be where there was only seven percent fee-for-service the last couple two years. That statistic has changed and we’re growing to see more and more fee-for-service, which is great. I like seeing that. The latest statistic is around like 18, 19% fee-for-service practices back into the U.S. But still, we have a ton of providers graduating out every year, and there are more and more providers building their own practices, joining as associates, and they need to be busy. And so, the “why” there is getting in-network with insurances and credentialing and becoming an in-network provider.” (2:20—3:08)

“Becoming a credentialed provider, it’s a process. It’s a process that has gotten increasingly difficult over the years. They don't make it easy. They don't want it to be easy. But they do want you to be in-network, and they really push for providers to be in-network and for patients to go to in-network providers. Now, the insurance companies send their EOBs out to the patients with, ‘If you would've gone to an in-network provider, your savings would have been X. Here’s a list of five providers in your zip code.’ They're promoting in-network. So, it is really hard to stay fee-for-service or to not go in-network. But we certainly don't want people to go in-network with the wrong insurances just out of fear either.” (3:11—3:49)

“My personal hypothesis [for why fee-for-service increased from seven to 18%] is COVID-19. Right before COVID-19, we were seeing seven percent. Now, it’s 18%. So, that gave providers time to look at how insurance...

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