The Waiting is the Hardest Part

Sep 13, 2022 at 02:02 pm by admin




Consider this common scenario: A new physician joins your practice – whether from out-of-state, residency, or another practice. Your practice is contracted with a multitude of payors including Medicare, Medicaid, TRICARE, managed care organizations (MCOs) that administer some of these programs, and various commercial payors. You’re busy, and you want your new physician to start seeing patients immediately. But before you can bill any of these payors, the physician needs to be credentialed and enrolled with each of them. It’s a time-consuming and convoluted process, different for each payor and full of many hurry-up-and-wait moments.

Our example describes a medical practice, but it’s not just physicians who require credentialing. Dentists, counselors and many other healthcare providers must also be credentialed by their respective payors in order to bill for the services that they provide. Some providers are waiting 30 days to as much as a year for MCOs and other payors to verify documentation, review applications, and make approval decisions. Unfortunately, this growing backlog for government and private payors can lead to the temptation to cut corners when submitting claims during the gap between application submission and approval, but by doing so they may ultimately create significant civil, and possibly criminal, liability.

So, how can a practice bill for a new provider’s services after a credentialing application is submitted but before it has been approved? Claims submitted for new and as-yet uncredentialed providers must be carefully considered in order to avoid compliance issues. A significant area of concern during the credentialing/enrollment process is the potential for a practice to bill for services rendered by new practitioners using the credentials of an already-credentialed provider in the same practice. Staff may see this as an easy way to avoid holding claims, but it comes with tremendous risk. Depending on how the claim is billed, it likely results in inaccurate claims being submitted, and any claims submitted by the still-un-credentialed provider may either be denied or, if already paid, may lead to overpayments. Medicaid and other government payors typically view such claims as fraudulent under the False Claims Act and other civil – and even criminal – laws. 

Most payors – including federal healthcare programs, MCOs, and commercial payors –retroactively approve providers’ credentials back to the date of application. This presumes, however, that the application is ultimately approved, and that the provider complies with all other requirements set forth by the payors. If a credentialing application is denied for any reason, whether it’s incomplete data, failure to meet the payor’s standards, or on any other basis, a new application must be submitted, and the retroactive approval date will typically be the new application date. This means that the period between the first application and the application denial is lost for purposes of submitting claims, and any claims submitted by that provider during that period run the risk of either being denied or resulting in potential overpayments.

Regardless of how a practice decides to handle new providers’ claims, it is imperative to understand each payor’s rules and regulations. Medicaid payors have increased their focus in this area. If a practice participates in government healthcare programs, additional attention must be paid to ensure that all claims are accurate and submitted for properly credentialed providers. Buyers considering the purchase of a medical or dental practice or practice management company would be wise to verify that no claims have been billed for non-enrolled/non-credentialed providers under another provider’s number. Failure to exercise due care in this area can lead to significant liability. 

JD Thomas is a partner at Waller and a former federal prosecutor. He advises healthcare clients in government investigations and prosecutions, qui tam and False Claims Act defense and other enforcement actions.

Andrew Solinger is an associate at Waller where he assists clients in responding to investigations, audits and other inquiries brought by federal and state government agencies and regulators.


Sections: Regulatory