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Selecting a Dental PPO Network Article Series

Download Recruiting and Credentialing article

Part 2

Recruitment, Credentialing, and Accreditation

You learned in Part 1 of the article series, “Evaluating Network Size”, how to measure the true size of a dental network.  In Part 2, you will learn how to evaluate a network’s quality by analyzing its recruiting, credentialing, and accreditation processes.

  

Recruiting

A dental PPO network should be actively recruiting new dentists to grow the network according to its pre-determined recruitment plan, in a way  that reduces costs to you and your members. This recruitment plan should consider historical data on provider utilization, out-of-network claims, geographic penetration, applicable ACA requirements, and member or carrier nominations. It is critical that a network recruitment plan be grounded in research in order to improve in-network utilization and plan savings.

                                  

Credentialing

Once a dentist has been successfully recruited, a network should objectively and consistently review that dentist using a comprehensive set of credentialing criteria. This criteria is a point of differentiation between networks, and is key to understanding the base-line quality of a network’s providers. You should fully understand each network’s credentialing criteria, and which components are administered in-house or by a third-party. Common credentialing criteria can include, but are not limited to:

  • Proof of all applicable current and past state and federal licenses
  • Current federal and state DEA certificates
  • Proof of liability insurance and professional liability claims history
  • History of sanctions
  • History of loss or limitation of privileges or disciplinary activity
  • Hospital affiliations or privileges
  • Background checks that disclose any physical, mental, or substance abuse that could without reasonable accommodation impede the dentist to provide care
  • Perform assessments of providers’ credentials, including routinely monitoring reports of disciplinary actions published by state licensing boards, the U.S. Department of Health and Human Services, the Office of Inspector General (OIG), the Excluded Parties List System (EPLS), the Office of Foreign Assets Control (OFAC), and the National Practitioner Data Bank (NPDB)
  • A signed and dated statement from the dentist attesting that the information submitted is accurate to the dentist’s knowledge
  • A signed and dated statement authorizing the network to collect any information necessary to verify the information on the credentialing application 

In addition to credentialing, learning a network’s approach to re-credentialing, on-going provider monitoring, and realtime provider maintenance can help you to evaluate the quality of a network’s credentialing criteria.

 

Accreditation

Several accreditation organizations are available in the health care market place. These non-profit organizations establish quality standards for the health care industry, including dental networks. An accredited dental network is an essential component to your quality review and demonstrates commitment to quality and accountability.

For a network to become accredited, it must undergo regular and comprehensive evaluations by an accrediting organization to ensure it meets industry standards and benchmarks. An accredited dental network has passed a documented process designed to ensure that policy and procedure standards are followed for: network management, recruitment, credentialing, auditing, compliance, and appeals. An accredited network will display a mark of distinction indicating a quality dental network is available to you, your customers, members, brokers, and other plan stakeholders.

 

Conclusion

Understanding how a network recruits and credentials providers will help you make a more informed decision when selecting a dental PPO network. Once more, network accreditation is a third-party ‘stamp of approval’ that a network’s policies and procedures follows documented standards of quality. This endorsement from a recognized accreditation agency can provide you with a level of confidence when selecting a dental PPO network.

Look for our final article in the Selecting a Dental PPO Network series to learn how evaluating a network’s access, utilization, and savings can help you determine a network’s true financial impact to your members and dental plans.

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Part 1

Download Network Size article
Evaluating Network Size

In this three part article series, we will look at several factors to consider when evaluating a network’s true value.
  
  • Network Size (Part 1)
  • Recruitment, Credentialing, and Accreditation (Part 2)
  • Access, Utilization, and Savings (Part 3)

Network Size

Often the first measure considered when evaluating the size of a dental PPO network are provider counts.  At first glance, looking at provider counts makes sense, but you could be short changing yourself.  Dental plans and networks market size differently.  It’s important to recognize how providers and locations are being counted to understand the true size of a network.


The most accurate counting methodologies to measure network size are unique providers or unique locations.  As illustrated in the example to the right, this is when a dentist or location is counted only once.  It’s simple and representative.


Access points are another counting methodology to measure network size.  However, counting providers and locations together can inflate the network count resulting in the illusion of more access.  For example, providers in a Dental Service Organization or group practice are counted at each location (4 unique providers and 3 unique locations equal 12 access points).  Practically, a member can only visit one dentist at one location at any given time. 


Large network counts may not translate to better member access or a larger network of providers.  All dental networks can provide unique provider and unique location counts so you can accurately evaluate to determine a network’s true size.

 

How Do You Count...XYZ Dental’s 4 Dentists and 3 Locations?

Do you know the unique provider, unique location, and access point counts?

 

  • Unique Providers = 4
    Dentists are counted once.

  • Unique Locations = 3
    Each office location is counted once.

  • Access Points = 12
    Dentists are multiplied by the number of office locations.

Remember! 

Provider counts should not be the only factor used to evaluate a network.

Return to Part 2: Recruiting, Credentialing, and Accreditation