For many practices, dental insurance payments reflect a sizable portion of their accounts receivable, and delays can have a devastating impact on their cash flow.
You may or may not be aware that the American Dental Association (ADA) has rolled out an updated version of their Dental Claim Form which went into effect January 2024. As with the previous version, it continues to provide standardization when reporting dental services to a patient’s dental benefit plan. Any dental practice that submits insurance must use the current form to avoid costly consequences. (1)
Hear directly from practice management coach and author Christi Bintliff as she explains how in this quick video…
Time is money! Sadly, we must play ball with the insurance companies by adhering to their rules of engagement. This is why it is so important that the Billing and Insurance Coordinators as well as the entire administrative and clinical team have a clear understanding of the importance of timely filing, and review of all claims to ensure that the required information, attachments, and documentation are provided and that any errors or missing information are being corrected before submittal.
The 2024 version provides new spaces for reporting data that can expedite timely and accurate claim reimbursement. We must now note services delivered by a “locum tenen” dentist, one who is standing in for another who is away from the practice for a brief time. Their National Provider Identifier (NPI) must also be noted on the claim.
In addition, the new form also supports reporting an identifier, known as Payer ID, that when available uniquely identifies the third-party payer receiving the claim. It also has a space to provide the date of the patient’s last scaling and root planing (SRP). (2)
Many of the practice management software, such as Eaglesoft are currently in form development and have not yet implemented the new version. They anticipate that the update will be released mid-year of 2024. (3)
However, this does not mean you should avoid providing the newly required information. Insurance companies are already starting to do a thorough review of the claims to determine if you are moving toward compliance. The 2024 ADA Dental Claim is copyrighted but a sample of the new form (4) as well as a tutorial (5) can be found on the ADA website.
I have identified one potential area of concern that you may encounter with locum tenens; are they an in-network (INN) or out-of-network (ONN) provider? Why does it matter?
The difference between an INN and ONN provider is very straightforward. INN means that the dentists have signed an agreement with a dental insurance carrier (or multiple carriers) to accept a discounted rate of reimbursement for the service they provide. And OON means the dentists have no signed agreement in place, and they are under no obligation to accept a discounted rate of reimbursement. (6)
Many locum tenens are often employed and temping on their days off to supplement their income. They are often an INN provider. Some are in between jobs or may be retired and have not requested to opt out of their INN agreements.
As mentioned, we are now required to include the name of the locum tenens along with their NPI whenever they provide services in your practice. We must understand that INN status is provider-specific, not practice-specific. This means their INN status travels with them from practice to practice for as long as they are under contract. (7)
Understanding this means that there is a high probability that an insurance carrier will remit a significantly lesser form of payment if the locum tenen is an INN provider. You may think it is related to an error with the insurance carrier, but it is most likely because the locum tenens is an INN provider.
I encountered a comparable situation when employing an Associate dentist. I was aware of their INN status and helped them request an opt-out with the carriers that they were under contract with. Because we are OON, it was important that the Associates’ INN status not trail to our office and disrupt our cash flow.
For the most part, I was successful. Due to an oversight, I failed to contact one of the carriers. I realized it when we received reimbursement and reviewed the explanation of benefits (EOB) noting that they had remitted the payment to us based on the Associate’s INN status. The payment was significantly less than anticipated.
It has never been on my radar regarding the locum tenens since we were not required to list them on the claim until this year. When this came into play, I contacted our dental placement agency to check the INN status of the locum tenens. I discovered that some were INN providers, a few whose status was unknown, and a few that were OON.
Many practices across the US, including the one I manage, have started receiving reduced insurance payments based on the locum tenens being an INN provider. For an OON practice that means a significant impact on their cash flow.
It is important that you contact any insurance carrier that reimburses you a reduced rate of payment based on the locum tenen’s INN status. I challenged the fact that the locum tenen “was not and will not” be a permanently employed provider simply on assignment from a temp agency. As you can imagine. I was unsuccessful in having their decision reversed. I am hopefully optimistic that this may be a fluke situation with insurance carriers or lack of a clear understanding and training regarding the new claim requirements. As time progresses, we shall see how this situation plays out.
It is important to talk with your dental placement agencies to learn more about the locum tenens. Their status with insurance carriers, their signed agreements and fee schedules has the potential to significantly impact cash flow.
Cited information:
- https://www.ada.org/publications/cdt/ada-dental-claim-form
- https://www.ada.org/publications/cdt/ada-dental-claim-form
- https://pattersonsupport.custhelp.com/app/answers/detail/a_id/43818
- https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/publications/cdt/2024_sampleadaclaimform_2024jan.pdf?rev=44ab7b51d54149ff8838a0a1ff68bb39&hash=5F14D821EDEB84E13A207A8B1D33A482
- https://www.ada.org/-/media/project/ada-organization/ada/ada-org/files/publications/cdt/2024_completioninstructions_adaclaimform_2024.pdf?rev=da5182e766e54bfb96c8c2e86261f57e&hash=EE8C7909A8C9F56FA0C1AE4FF9CB457D
- https://www.ramseysolutions.com/insurance/in-network-vs-out-of-network#:~:text=What%20we%20are%20talking%20about,no%20signed%20agreement%20in%20place.
- https://tidewaterdentalconsulting.com/2023/07/29/enhancing-efficiency-and-precision-in-dental-insurance-claims-the-2024-ada-dental-claim-form/
