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Credentialing versus contracting - these terms are often used interchangeably in dental offices, but as Ericka Aguilar explains in this essential episode, they represent entirely different processes with significant implications for your practice's compliance and financial health.
Credentialing is the verification process where insurance companies confirm a provider's qualifications, while contracting is the business agreement that follows, officially making a provider "in-network." Understanding this distinction is just the beginning of navigating the complex landscape of dental insurance billing.
The episode delivers a stark warning about one of the most dangerous practices happening in dental offices today: billing under another provider's NPI when that provider didn't perform the treatment. This typically occurs when practices are waiting for a new associate to complete the credentialing process. What many don't realize is that this practice constitutes insurance fraud, violating state and federal regulations. With insurance companies now employing AI and aggressive auditing techniques, the risks of massive recoupments, civil penalties, and even criminal charges have never been higher.
Erica also demystifies Locum Tenens arrangements, which provide a legitimate pathway for practices to maintain continuity of care when a provider is temporarily unavailable due to specific circumstances like maternity leave, disability, or death. However, these arrangements come with strict limitations that must be carefully followed to avoid compliance issues.
Through real-world examples and practical advice, this episode equips dental professionals with the knowledge to protect their practices while maintaining ethical standards. Whether you're a practice owner, office manager, or dental biller, the insights shared will help you navigate the credentialing process correctly, understand when Locum Tenens is appropriate, and implement documentation practices that keep your practice on the right side of compliance. Visit dentalbillingdoneright.com to learn more about setting up proper credentialing SOPs and claim auditing for your practice.
Download "The Most Underused Codes in Dentistry - And How to Get Them Paid" checklist here:
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