Dental Insurance Transition Issues

Transition Issues Related to Dental Insurance

We often get questions regarding the transfer of ownership and complications with dental insurance networks.The following is for information purposes. Any advice and/or opinion in regards to legality, validity, effect, tax and/or other consequences pertaining to any transaction and/or any documents must be provided by the recipient's attorney and/or accountant.

Here are some answers to the most common questions asked by clients:

• Is the buyer able to bill under the seller’s information?
  Many buyers assume they are going to bill under the seller’s tax ID number and this is often what they are asking when they want to bill under the “seller’s information.” The ADA claim form has a location for the billing entity (Practice Name, Tax ID Number, NPI2, and Billing Address) and a separate location to disclose the providing doctor (Provider Name, License Number, NPI1). To be reimbursed by insurance networks the “provider” not “entity” must be credentialed (Medicaid requires both the entity and provider to be credentialed). For this reason, even if the buyer submits a claim form under the seller’s tax ID number they still need to disclose that they are the provider rendering treatment. Billing under the sellers Tax ID number is not recommended unless the seller is staying on as an associate after the transition.
  
  We do not recommend billing under the seller’s tax ID number after closing.
   
• What happens if the buyer bills under the Seller’s Tax ID?
  At the end of the year, the seller will receive a 1099 from each insurance billed under their tax ID number showing income that went to the buyer. The seller will need to 1099 the buyer’s entity for this income. Please consult your attorney and CPA before billing under the seller’s tax ID number.
   
• Can the buyer bill under the seller’s provider information (Name, License, Personal NPI)?
  No, if the buyer is rendering treatment then their name, license number, and personal NPI number needs to be on the claim form.
   
• Is insurance credentialing based on the Tax ID (billing entity) or Provider (doctor rendering treatment)?
  Provider. However, each provider must have their new location and TIN added to their credentialing with each insurance company before they are able to bill as an in network provider at that location.
  
  *Medicaid requires the entity and provider be credentialed.
   
• Can I start credentialing with insurance before the office staff has been informed of the transition?
  No, the insurance company will occasionally contact the office to verify the new provider and billing information. This contact may be by phone, email, fax, or mail. The insurance providers will not agree to maintain confidentiality.
   
• If I am in-network at another location, do I have to re-credential when purchasing a practice?
  Yes, insurance companies do require full or partial credentialing when moving to a new location. If you are moving from out-of-state then you will likely need to complete a full credentialing application with most insurance plans.
   
• Can fees be negotiated after I credential at a new location?
  Insurance plans that allow fee schedule negotiations usually require a submitted request during the initial credentialing application.
   
• How long does the credentialing process take?
  30-120 days for most insurance plans.Medicaid can take longer depending on the state.
   
• Can I bill as an out-of-network provider for a time until my credentialing is complete?
  Yes, you can bill out-of-network.Some insurance plans do not have out-of-network benefits for patients, so it is recommended that your office check eligibility and benefits before rendering treatment.Some insurance plans may send the payments to the patients if you are not-in-network.