Q&A: Billing options for physicians who aren't yet credentialed

April 3, 2009

How should we bill care provided by a physician who doesn't have her credentials yet?

Q: We have a new physician who started recently and has not been credentialed through any insurance companies. (Her applications are being processed.) A billing department told us that we could bill her services under another physician. It is my understanding that a physician cannot be incidental to another physician, and we must see the patient at no charge, advise the patient that the doctor is "non-participating," or schedule the appointment at a later date when the physician is approved. We have difficulty if the doctor is on call for the group and must perform obstetrical functions. Can you offer any insight?

A: Some insurance companies, and Medicare, will allow a physician's credentialing, once approved, to be retroactive to the date the application was received. However, the majority of insurance companies do not allow retroactive credentialing. You are correct that only non-physician practitioners can bill incident-to services, and physician services must be billed by the performing physician. Billing Physician A's services under Physician B's national provider number is not appropriate, even in a group practice. Therefore, it is extremely important to enroll physicians as soon as possible in order to be reimbursed for their services. Someone on your staff should be designated to this task, and that employee should follow-up regularly with each insurance company in order to expedite the credentialing process.

Until your physician is enrolled, you are correct that you can:

2) See the patient at no charge.

3) Advise the patient that this physician is not credentialed in his or her plan yet, and schedule a later appointment.

Try these options in the order listed. Unfortunately, the risk of losing a patient increases if he or she can't count on all your group's physicians being in his or her plan. In on-call situations, you should strongly consider writing off the charges for the uncredentialed physician. This is the best way to keep a good physician-patient relationship.

Send your practice management questions to mepractice@advanstar.com (please include your regular postal address). Answers to our readers' questions were provided by Steven I. Kern, JD, of Kern Augustine Conroy and Schoppmann in Bridgewater, New Jersey; Lee J. Johnson, JD, healthcare attorney in Mount Kisco, New York; and Judy Bee of Practice Performance Group in La Jolla, California.