Billing for non-credentialed providers is a question that physician practices constantly ask from physicians medical billing companies. There are multiple reasons due to which practices want to bill for the services of a non-credentialed provider.
There might be an addition of a new physician in the team and that physicians credentialing takes time and the practice owners want claims to be submitted. Although, it is best in the interest of the providers to get credentialed first and only then provide services obviously credentialing is a time-consuming process and mostly requires services of credentialing consultants.
The best way is to start the physician credentialing process as early as the physician signs the contract to come on board, so that the credentialing process may coincide with the hiring process.
It is assumed that if a new provider is not registered then his services can be billed under the National Provider Identifier (NPI) number of another physician who is registered and is serving in the same specialty.
This can happen but in a certain context and out of it CMS has clearly stated that billing by using another physician’s NPI is strictly prohibited. It is termed illegal and if any physician is found guilty of doing it then the government can apply huge penalties.
It is easier to trace nowadays when time and quality measures are reported in real-time and increased billing can cause problems. So, such an action can lead to an investigation or audit by the payers. In such a case an Oklahoma physician was found guilty and was fined $580,000 for the violation of the law.
The physician allowed the employer to bill under his NPI for the services and procedures that he never performed nor supervised. There are multiple other examples where providers tried to bill for the services by using the NPI of physicians who didn’t perform those procedures. So such an act must be avoided in all circumstances.
If a practice has changed its name or merged into another entity and which requires new registration and tax ID, then standard procedures must be followed and which requires fresh registration of every physician at the new business entity.
In another scenario, a physician leaves the practice for a certain time or is temporarily absent and the practice arranges a substitute physician to serve in the absence. In that case, Medicare allows temporary billing for the substitute physician under the circumstances when the on-staff physician is absent.
This is billing for locum tenens physicians and is only allowed when an in-house physician goes on holidays or is absent due to some other reason and a temporarily hired physician provides services in the absence period. However, in the ‘ locum tenens’ scenario, the locum physician can only bill for a maximum of 60 days period.
Even when practices take into consideration all the necessary measures they must take extra care when they are preparing and submitting bills under such arrangements.
- They must use the right NPI of the provider. Practices must understand that if they are using individual NPIs to bill for services or they got organizational or group NPI.
- Billing to private insurance companies, all the requirements must be understood in advance to be saved from possible objections. The best way is to take authorization from private companies.
- Even billing to Medicare, practices must ensure that each requirement is properly met.
- Under the ‘locum tenens’ scenario, there is a 60 days limit. However, physicians must understand that days off are also included in that 60 days time period which starts from day 1 of the locum physician. The only exception to this 60 days limit is if the absent physician is serving in the armed forces and is called on active duty.
- Locum Tenens billing only applies to Medicare, while billing to Medicaid the practices must meet the requirements of private companies.
- Modifier Q6 must be appended at the end of CPT codes, in the locum tenens physician billing.
Even when a temporary arrangement allows practices to submit bills, they still need to use to cautiously. They should always check with the private insurance companies that what level of leniency they offer. Practices must know each detail of the legal agreement and must figure out exactly the option to bill for non-credentialed providers.
Billing for the non-credentialed physician is a question that we come across quite often as physicians credentialing services provider. However, we remain wary of this and guide our client practices at every step to save them for any possible violation of the law and subsequent penalties.
We work closely with our physician practices by professionally handling their credentialing requirements and handling locum tenens physician billing.
Also Read- How to Transition from Employer Coverage to Medicare at Retirement