Submitting Dental Claims Under the Correct Rendering Provider - Best Practices

In today’s fast-paced dental environments, it can be tempting to “simplify” claim submissions, especially when multiple providers are involved, schedules shift, or production is heavily team-driven. However, accurately reporting the rendering provider on every insurance claim is more than just good office protocol. It is a legal requirement, a cornerstone of ethical billing, and a critical safeguard against insurance fraud.

Below, we break down why this matters, when mistakes commonly occur, and what the consequences can be if claims are not submitted correctly.

What Is the Rendering Provider?

The rendering provider is the licensed dentist who actually performed the clinical service. This is the individual who:

• Examined the patient

• Diagnosed the condition

• Performed the procedure

• Is legally responsible for the care delivered

Insurance companies rely on this information to determine coverage, network status, eligibility, and reimbursement.

Why Dental Offices Sometimes Submit Under the Wrong Rendering Provider

Even well-run offices encounter situations that can lead to incorrect submissions. Common reasons include:

• “It pays better under another doctor.”

  • A practice might be tempted to submit under a doctor who is in-network, has better contracted fees, or receives higher reimbursement rates.

  • Why this is a problem: This is considered misrepresentation and is a classic form of insurance fraud.

• Associate vs. Owner Provider Confusion

  • Some practices default to listing the practice owner or main billing provider on all claims, even when associates performed the work.

  • Risk: Insurance companies may recoup funds, terminate provider contracts, or investigate the practice for falsification.

• Provider Credentialing Delays

  • When a new dentist isn’t credentialed yet, offices sometimes submit under another provider "just until the credentialing goes through."

  • Important: Insurance carriers view this as intentional misrepresentation. It can jeopardize credentialing, trigger audits, or even be deemed fraudulent.

• Patients Requesting a Specific Dentist on Paper

  • Rarely, a patient may prefer that their “regular dentist” be listed for continuity.

  • However: Claims must always reflect factual, not preferred, information.

    
    

Legal and Compliance Implications

Submitting claims under the wrong rendering provider can have serious consequences.

• Insurance Fraud

  • Most insurance carriers—and state laws—define fraud as knowingly submitting incorrect or misleading information to obtain payment. Using the wrong rendering provider falls squarely into this category when done intentionally.

• Recoupments

  • Insurers can demand repayment of all affected claims, sometimes going back years. These amounts can be substantial and create financial strain for practices.

• Loss of Provider Credentialing

  • Carriers may suspend or terminate participation agreements, restricting a provider’s or practice’s ability to treat insured patients.

• Fines, Penalties, and Legal Action

  • State dental boards, CMS (if Medicare/Medicaid involved), or insurance fraud divisions may impose:

    • Civil fines

    • Criminal charges in extreme cases

    • Disciplinary action on a dentist’s license

• Damage to Practice Reputation

  • Beyond financial consequences, inaccuracies in claim submissions undermine patient trust and the practice’s professional reputation.

    
    

How to Ensure Claims Are Submitted Correctly

• Implement Clear Provider Workflow Protocols

  • Track which doctor performs each procedure, even when multiple providers touch a case.

• Properly Set Up Your Practice Management Software

  • Your system should default to the correct rendering provider based on appointment and procedure data—not based on the billing provider.

• Require Credentialing Before Treating Insured Patients

  • Avoid the “just until credentialed” trap.

• Train Administrative and Clinical Teams

  • Everyone should understand:

    • Why correct rendering provider matters

    • What the legal risks are

    • How to properly document services

• Conduct Regular Audits

  • Randomly review a sample of claims each month to catch inconsistencies early.

    
    

Final Thoughts

Submitting claims under the correct rendering provider is not optional, it’s a legal and ethical requirement that protects your practice, your patients, and your providers. While shortcuts may seem harmless in the moment, they can lead to severe consequences down the road.

A compliant office is a healthy office. By applying best practices and ensuring accurate reporting on every claim, you reinforce the integrity and long-term success of your dental practice.