ED Coding and Reimbursement Alert

Question:  A new physician started at our emergency department practice, but he hasn’t received his insurance credentialing yet. Can we bill for his services?

Codify Subscriber

Answer: When you can bill for a new physician’s services depends on when you’re able to get him credentialed. You’ll also need to know the differences between the payers you’ll be reporting the services to, because they do not all follow the same policies.

For Medicare, you’re allowed to bill 30 days retroactively. Regardless of when the provider starts with your practice, you’ll only be able to retroactively bill Medicare for services your physician rendered up to 30 days prior to the date he received his Medicare credentialing status.

How it works:  Suppose you hire a new physician who recently applied for Medicare status but has not yet received his credentials. He sees several patients each day over a three-month period, at the end of which he receives his credentials.

You’ll only be able to retroactively bill for the work the physician performed during the final 30 days prior to his credentialing. The other two months of work are not billable.

CMS provides the below example:

If a provider starts with a group on May 15, 2019 and CMS receives the application on June 30, 2019, they will only retroactively pay for services 30 days from the receipt date. If a provider starts July 1, 2019 and you submit the applications on May 1, 2019, you will receive the July 1, 2019 effective date.

The date depends on how you’re submitting the application as well. If you submit the application via the Provider Enrollment, Chain, and Ownership System (PECOS), you have 30 days from the day you submitted the enrollment application to the Medicare carrier.

Private payer difference: Check with the individual payer as the rules vary. Some may give you an effective date for when you can start billing. Most payers will not take claims from dates of service prior to the date when they approved the physician as a credentialed paneled participating physician with their plan.