Practice Management Alert

Starting Jan. 1, you can't retroactively bill back 27 months

Billing for a new provider can be an absolute nightmare of denied claims and lost reimbursement. And as of Jan. 1, that nightmare gets a bit scarier if you-re billing Medicare for your new provider's services.

Why: According to the 2009 Medicare Physician Fee Schedule, 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.

That's a huge difference from the current rules, which give you a full 27-month window during which you can retroactively bill. Despite several comments from medical practitioners requesting more than the allotted 30 days, CMS stood firm in its decision to reduce the pre-credentialed billing period.

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.

Old way: You would have retroactively billed Medicare for all of the services the new physician performed during the three months prior to his credentialing.

New way: 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.

"You can no longer just bill Medicare while waiting for your credentialing approval, unless the services were performed 30 days prior to the Medicare approval," says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. "And you have no way of knowing when your approval will happen; it's a guessing game."

Warning: You should not use another credentialed doctor's national provider identifier (NPI) on the new doctor's Medicare claims to get paid for services the new physician performs before being credentialed. Doing this is considered fraud since your practice would be saying that Doctor A performed a service that Doctor B actually provided. Either avoid having the new physician see patients until the Medicare credentials come through, or have the physician see only non-Medicare patients who are self-pay or who have insurance that allows you to bill before credentialing.

If you-ve seen credentialing drag on for months, you may benefit from a new government program. You may be able to speed up your credentialing by using the Provider Enrollment and Chain/Ownership System (PECOS), says Quinten A. Buechner, M.S., M.Div., CPC, ACS-FP/GI/PEDS, PCS, CCP, CMSCS, with ProActive Consultants in Cumberland, Wis. "But don't get excited if you can-t. Keep trying, as it will be in place by Dec. 31," he advises.

What is it: PECOS is an Internet-based Medicare provider enrollment process system that allows physicians and non-physician practitioners to enroll, make changes to their Medicare enrollment information, or track the status of their Medicare enrollment applications throughout the enrollment process. Basically, PECOS is used to collect and maintain the data practices submit on CMS 855 enrollment forms.

PECOS is currently established in 24 states, and CMS says it cuts enrollment time to half of what it was with paper enrollment. You can check out the PECOS system online at https://pecos.cms.hhs.gov.

To review the fee schedule and learn how to submit comments, visit the CMS Web site at www.cms.hhs.gov/physicianfeesched/downloads/CMS-1403-FC.pdf.