Claims for Owners and Associates in Group Dental Practices
Dentists could work for corporate, with a family, other dentists, or other types of group practices (Prescott 2017). When dentists become associates at group practices, they may either be in the owner’s insurance network or not (“Dental benefits 101: Proper billing, waiving copayments” 2016). To avoid fraud, group practices’ claims must differentiate between owners and associates.
These practices must classify the dentist, regardless of his or her insurance networks, that cared for the patient. Their claims must indicate not only the owner, but also the associate dentist that treated the patient (“Dental benefits 101: Proper billing, waiving copayments” 2016). If the claim indicates that the patient is treated by an associate not in his or her insurance network, the patient would receive out of network benefits, regardless of whether the practice’s owner is in the patient’s network (“Dental benefits 101: Proper billing, waiving copayments” 2016). If the owner wants the associate to be in his or her network, the owner must deal with this matter “in the associate agreement between the practice owner and potential associate” (“How to contract with and bill for associates” 2016). According to the California Dental Association’s (CDA) article, “How to contract with and bill for associates,” the insurance company may also sign different contracts with the owner and the associate “[due] to changes in the dental benefit marketplace, and changes in benefits made available to their enrollees…” (2016). Meaning, the owner and the associate may have different fee schedules (“How to contract with and bill for associates” 2016). This 2016 CDA article also states, “When a practice hires an associate, the practice must contact each plan the practice wants the associate contracted with to determine how best to proceed. Plans will need to update their claims processing system and associate the treating dentist to the billing entity or corporation to prevent claim rejection.”
The practice commits fraud when it does not correctly list the dentist, such as the owner and the associate, that cared for the patient as in network or out of network (“Dental benefits 101: Proper billing, waiving co-payments 2016; Milar 2014). In this event, according to Ann Milar, “CDA dental benefits analyst,” these clinics could “[receive] a termination letter or notice from a plan… This notice is usually accompanied by a request for a refund from the dental practice for the work that was incorrectly billed, sometimes to the tune of $100,000 or more” (2014). In order to avoid incorrect billing, Milar states, “Dental plans conduct office and claim audits to verify that charting, billing and coding is in alignment with the benefits paid on behalf of their enrollee (your patient)” (2014). On the clinics’ part, they should “revisit their system of checks and balances to ensure patient charts, billing records, claim submissions and appointment schedules correctly reflect the provider who actually rendered treatment” (Milar 2014).
While group practices may appeal to some dentists, they must know which associate provided treatment. By doing so, they avoid committing fraud in their claims.