Q&A: Billing before credentialing

September 5, 2008

Doctors not yet credentialed can bill for services in some states.

Our new physician is not yet credentialed with all the plans the group participates in. Since most insurance plans will not allow retroactive billing, can we allow the new physician to see patients and bill the new physician as "incident to" the senior physician so long as the senior physician is in the office?

Medicare Part B Reference Manual, Chapter 13.3Medicare Reimbursement "Incident To" Services (CMS Manuals Publication 1002; Chapter 15; Section 60) defines "incident to" services as those services and supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. In other words, these services do not represent the major portion of the overall service provided by the physician. Given that definition, you could not bill the new physician's services as "incident to."

However, several states have passed legislation (Texas House Bill 1594 and Ohio House Bill 125, for example) requiring that new doctors to a group be provided provisional credentialing status as soon as they apply and can bill their services as if they were credentialed with the plan. New physicians may not be listed in the provider directory for that plan until credentialing is complete, but they may see patients and bill for their services. This state-specific legislation does not apply to Medicare or Medicaid. Medicare does allow retroactive billing without penalty, however.

The author, vice president of operations for Reed Medical Systems in Monroe, Michigan, has more than 30 years of experience as a practice management consultant, and is also a certified coding specialist, certified compliance officer, and a certified medical assistant.

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