What should I be aware of when considering contracting with a plan to join its provider network ?

While the law is often silent about the relationship between health plans and the providers who contract with them, much that affects your responsibility to the plan and theirs to you is specified in the contract that plans have with providers.

When considering signing a contract to become a provider in a plan’s network, consider the following: What limitations and exclusions does the plan place on the payment of claims? Does the plan require you to collect patients’ copayments? Does the plan have a system of utilization management, which will involve postpayment review of claims to discover patterns of over-utilization of certain procedures? Does the contract specify limitations and exclusions from coverage for the plan for which you are considering joining the network?

What does the contract say about periodic audits of your office for quality assurance reviews or financial practices? Does the contract refer to other documents such as a dentist handbook, which details what procedures the plan will pay for and what documentation is required? What is the means of terminating the contract for both parties? Is there a continuity of care provision that will require you to continue to see the plan's patients who are in-treatment even after you have terminated from the contract? In addition, how long does that continuity of care period last? These are just a few of the provisions you may want to consider before signing a plan contract.

The American Dental Association provides a service to members of analyzing plan contract provisions and providing comments. This service is available through CDA, which provides previous ADA analyses and or forwards new contracts to ADA for analysis. Contact CDA Practice Support for these analyses.

Dentist Problems In Billing Forms With Patients

Common questions & answers with patients insurance collections and dental benefits plans.

What can I do if a patient refuses to pay for what insurance won't cover ?
When the parents are divorced, who should pay for a child's treatment ?
Is it reasonable to check my patient's credit history before I start treatment ?
Can I charge interest for late payments ? If I do so, am I required to notify patients before I start charging interest ?
What notices am I legally required to provide patients to whom I offer third-party financing ?
What if the patient doesn't return for completion of the treatment and the dental plan has already paid for it ?
Can I offer a discount to my patients who pay in full prior to treatment ?
Are there legal problems in giving discounts to family, staff or colleagues ?
If a patient is behind on payments, can I withhold records or stop treatment ?
How do I collect an unpaid balance if the patient is in bankruptcy ?
A patient is owed a refund from overpayment, but I cannot locate the patient to send the refund. What do I do with the funds ?
What do I need to know about working with a collection agency ?
What are the federal and state laws that apply to my collection efforts ?
Is there a statute of limitations for collecting debt ?
Is small claims court an option for collecting unpaid bills ?
What should I do if a patient isn’t satisfied with the quality of treatment and wants a refund ?
Should I use the fee allowed by the plan for each procedure or my own usual, customary and reasonable (UCR) fee ?
Can I waive patient copays ?
Can I establish a discount program in my practice for patients, and what are the legal requirements ?
How soon must I submit a claim in order for it to be considered valid ?
How soon must a dental plan or insurer pay submitted claims ?
What options do I have if I disagree with the insurance plan's payment decision ?
A dental plan is auditing my practice - what does this mean ?
Does an auditor have the authority to access patient records ?
How can a dental office prepare for an announced audit ?
What if the office fails the dental audit?
Are plans required to pay for in-hospital dental treatment ?
Does obtaining a prior authorization from a patient's plan obligate the plan to pay for that treatment ?
Can lab costs be charged on a claim separately from a procedure ?
Must refund demands from dental plans always be paid ?
What should I be aware of when considering contracting with a plan to join its provider network ?
Can I balance bill a Denti-Cal beneficiary for the portion of my bill that wasn't paid by Denti-Cal ?
May I charge a Denti-Cal patient for an alternative procedure that is not a covered benefit of Denti-Cal ?
Must an associate dentist in my office be separately enrolled as a Denti-Cal provider if I am enrolled as a provider ?
What is the best way to obtain information about the treatment, provider participation and payment policies of the Denti-Cal program ?
How and when your practice verifies patient insurance coverage ?
What medical plans will pay for in dental operations ?

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