Credentialing new physicians

July 25, 2008

Is it legal to employ a physician on Aug. 1, 2008, and utilize her as a salaried physician to see patients and bill under another physician as the billing provider for 60 days?

Q: Is it legal to employ a physician on Aug. 1, 2008, and utilize her as a salaried physician to see patients and bill under another physician as the billing provider for 60 days? We have had her NPI, CAQH, medical license and her DEA for over a month but in our area the insurance companies that we participate with are out 90-120 days for credentialing. They also do not do not allow retroactive billing. We have a doctor after almost nine months of searching, and we just want her to be able to start seeing patients. Any suggestions?

A: The problem that you raise is a common one that is faced by many medical practices; unfortunately, it is also a problem for which there is not a good answer. Any practice that bills in the name of one physician for services actually rendered by another physician would most likely violate the Federal False Claims Act for claims submitted to a federal health care program and may also violate the prohibitions on health care fraud implemented as part of HIPAA, as well as state insurance fraud rules targeted at the submission of false claims (depending upon the laws of the state in question) for claims submitted to both federal health care programs and third-party payors. Many practices try to leave themselves with enough “lead time” to get a new physician credentialed with third-party payors prior to their actual start date, but this is often impossible or impractical, and as you noted, many private payors do not permit retroactive billing. In fact, CMS is soliciting comments on the issue of the effective date for Medicare billing privileges for suppliers in the proposed 2009 Medicare Physician Fee Schedule, which may eliminate retroactive billing for Medicare in the future. The best advice is to start the credentialing paperwork as soon as possible and to prepare for a cash flow crunch when the new physician starts if a practice is not able to immediately bill for all of the services that are being provided by a new physician.

Michael R. Burke, Esquire, is a shareholder with the health care law firm of Kalogredis, Sansweet, Dearden and Burke, Ltd., located in Wayne, PA.

The answers to these queries are general opinions and are not intended as substitutes for legal advice. You should not rely on these replies in making decisions involving questions of law, but should instead consult with competent legal counsel.