How to Bill for Non-credentialed Providers?

Your service claims will be accurate if you know how to bill non-credentialed providers. This will also help you avoid regulatory errors that could lead to audits and, worse, fines. For a non-credentialed clinician who is new to your urgent care practice, it can be difficult to comprehend how to bill and receive payment. Here is the list of causes:

Reason #1: Permanent Full-time or Part-time Recruit

In care facilities, new providers are expected to manage more patient inflow. A clinic owner may not have four to six months' notice to fully credential a new clinician, especially if the need is unanticipated.

Reason #2: Temporary or Substitute Hire

Due to an unanticipated loss of a doctor like leave without prior notice or termination, the care facility may need to fill the vacancy at the earliest. Or else, it could be a temporary arrangement if a clinician is absent for reasons such as illness, pregnancy, vacation, or other reasons.

Hence, care facilities frequently utilize a non-credentialed provider. At the same time, they would request the billing companies to either bill for the new doctor under another specialist's name or the facility's name.

The response is: It depends on the circumstances. It is essential to keep in mind that while commercial insurance carriers each have their requirements, Medicare has its own set of rules that are distinct from those of other insurance payers.

Billing for Permanent Full-Time or Part-time Recruits without Credentials

You'll have to give close consideration to your payer contracts to charge for non-credentialed and non-contracted providers accurately. You cannot bill for services provided by your new provider if the health plan only allows credentialed clinicians to provide services and the new provider is not replacing anyone.

Even if the contract is under the practice's name, billing for services that were not provided by a credentialed clinician or by a credentialed substitute filling in for a previously credentialed provider would violate the health plan's contract. The health plan may only require physicians to be credentialed in some instances; in some plans, all providers physicians, and mid-levels are required to have credentials and be bound by the contract.

On the other hand, if the health plan does not require medical staff credentialing, you can bill new clinicians under the clinic name. In those cases, most health plans simply need a refreshed program of providers offering administrations under the center arrangement.

To bill Medicare, permanent full-time or part-time providers must be credentialed.

Billing for a Temporary or Substitute Hire without Credentials

In the second scenario, when a provider leaves or is temporarily replaced, the answer is more difficult. Here are the billing options you can try.

  1. Arrangements for Locum Physicians

A locum physician is a substitute physician who does not intend to join the urgent care practice but rather serves as a replacement. Only 60 days are allowed for locum physicians to practice and bill.

  1. Commercial Insurance Carriers

The Q6 modifier service provided by a locum physician is added to each CPT code on the claim when billing for locum physician services under the NPI of the doctor absent. It is not necessary to indicate the substitute services on the claim. The locum physician's NPI must be included in the record of patients seen by the practice. The locum physician receives the same fee-for-service or daily rate from the on-staff physician.

  1. Medicare Rule for Locums

When an assignment is accepted, Medicare requires that an on-staff physician be able to bill and receive payment for the services of a substitute physician just like they were performed by the on-staff physician. Locum physician billing can also be used if an on-staff physician has left your practice and is unable to provide services. Each CPT code on the claim must also have the Q6 modifier added to it. Each locum physician has a 60-day consecutive limit, which begins with the first patient seen (even if patients aren't seen on certain days when a doctor is on vacation, has a day off, etc.).

Tips for Using Non-Credentialed Providers

If your practice's billing needs cannot be met with locum providers, don't give up hope. There are a few choices that can help you fill in the gaps while your providers get the right credentials. Here is the list:

  1. Realize your health plan contracts well — and comprehend the most ideal way to charge for non-credentialed doctors, so no infringement will happen.
  2. Restrict non-credentialed providers to self-paying patients only.
  3. Provide sports physicals, occupational medicine, and other non-credentialed services to non-credentialed providers.
  4. Schedule additional visits to non-credentialed employees to assist with workload until they receive their credentials, if commercial insurance permits it.
  5. Connect with patients who opt for a non-credentialed doctor in order to utilize a payment plan or other alternatives.
  6. Begin medical staff credentialing as soon as possible—even during the interview phase—so that by the hire date, their credentialing will likely be complete.

Non-credentialed providers will keep on coming under scrutiny. Work with medical credentialing service agencies like ProLocums who can help in getting your doctors credentialed at the earliest. Make use of our expertise in medical credentialing service.

Prolocums icons Prolocums icons