Q&A: Billing for physicians awaiting credentialing

December 5, 2008

The window of opportunity to retroactively bill for services for a physician awaiting credentialing has been reduced from 27 months to 30 days.

We recently heard that CMS has shortened the time frame during which we can file retroactive claims for providers who are in the process of credentialing. We are a large primary care practice with multiple locations in two states, and we're concerned that a limitation on our ability to retroactively bill for the services provided to a physician in the credentialing process will seriously hurt our income, since it seems we are constantly in the process of credentialing. What are the details?

The Medicare Improvements for Patients and Physicians Act not only set the 2009 conversion factor and eliminated the budget-neutrality adjustment to the work relative value unit, but it also limited the ability to retroactively bill for the services of a provider who is in the credentialing process. The window of opportunity to retroactively bill for services has been reduced from 27 months to 30 days. In addition, the time limit to provide additional information to a claim has been reduced from 90 days to 30 days, as has providing any changes to your group, such as adding a physician or location. CMS has indicated there will be takebacks if services are rendered in a lower-payment locality.