Practice Management Alert

Don’t submit to myths or magical thinking when submitting claims for providers without credentials.

As the COVID-19 public health emergency (PHE) drags on, healthcare workers face burnout, and staff turnover may build. If you are in a position of figuring out how to accommodate new providers, especially clinicians who may be nonphysician providers (NPPs), you’ll need to navigate some ethical intricacies of coding and billing for maximum reimbursement.

So what do you do if you have a physician or NPP who is starting at your practice but not yet credentialed? Read on to find out.

Don’t Let Prior History Cloud Your Gut Judgement

Figuring out the personal and sometimes hierarchal chemistry among staff members can be tough when someone new joins the team. Myths, legends, convenience, and magical thinking can cloud folks’ judgement, despite billing and coding being designed to be largely objective endeavors. Every time a new person joins the team, you have a new opportunity to get things right and to stick with the correct way of doing things.

For example, submitting claims for a not-yet-credentialed provider under a colleague’s National Provider Identifier (NPI) is risky business, to put it mildly.

“I would not bill under a provider who did not render the service unless it falls under incident-to or locum tenens. Both of these do not apply to one nurse practitioner submitting under another nurse practitioner,” says Christine M. Speroni, CPC, administrative office manager at NHPP Gynecologic Oncology in Ronkonkoma, New York.

“I cannot tell you how many times I have heard in my career ‘but we’ve always done it this way,’” Speroni says. “Having done it incorrectly in the past does not justify doing it incorrectly in the future. This could be considered fraud, as you are intentionally submitting dishonest information in order to receive payment.”

Fill Provider’s Schedule Where You Can

Speroni says she tries to get any new provider’s credentialing going as soon as possible.

“I try to do this before provider has even started. I start the process the day the employment contract is signed,” she says.

In the meantime, you need to be able to shunt work to the new provider, but not risk noncompliance or losing money. Here is where the office manager needs to be smart about business.

“I try to maximize the amount of work they provide that is either not paid or billable correctly,” Speroni says. The new provider can perform services related to post-operative visits, prescription renewals, patient phone calls for triage or results, or afternoon hospital rounds after another clinician has performed morning rounds, she suggests.

“Once, they start becoming credentialed, keep an updated list of those insurances and funnel patients with those plans to the new provider. Schedule all self-pay patients with this new clinician,” she says.

Make These Tweaks for NPPs

You have to follow and navigate more rules to make sure your NPPs get paid.

“If the new provider is an NPP, schedule as much as possible that could be billed incident-to a physician,” Speroni says. But make sure you have a handle on the specifics, including that the the physician must be on-site and already determined the treatment plan.

Some commercial carriers don’t credential NPPs and prefer that services are billed under a physician. Make sure you check your current carriers and contracts to know how to fill out your providers’ schedules while also doing what you can to make sure they’re paid for their time.

Pocket This Trump Card

Playing only by the specific rules for individual carriers may overwhelm or overburden some providers, or even leave patients without the care they need.

If you find that you need a workaround to provide some aspects of patient care, you can use the new provider for care services you know won’t be covered by insurance carriers. In this situation, you could decide to provide those specific services for free.

“Create a dummy code in your system that does not get billed to insurance to track the work for your own knowledge (provider metrics, etc.). You could inform patients that the provider is not credentialed and that they would be billed for any insurance applied deductible/co-insurance. I would have them sign an acknowledgement of this. Some carriers could require a specific form for this,” Speroni says.

Prioritize Compliance

If you hear a longer-serving colleague say XYZ is just “the way we’ve always done it,” but you believe that such billing is bad judgement or possibly even fraudulent, speak up.

If you have a compliance department or some other compliance expert you can consult, they can provide a definitive answer for your specific scenario.

“Issues like this are sometimes best handled by a compliance department (if you have one),” Speroni says. “Often it’s just simply a lack of knowledge about how incorrect this is. Educate the practice and offer collaborative solutions.”

Consider using Speroni’s suggestions as a foundation or a starting point.