How to Bill for Non-credentialed and Non-contracted Providers – Part 2
Medical Billing

How to Bill for Non-credentialed and Non-contracted Providers – Part 2

In part one of this blog series, we examined the common urgent care industry question if a practice can bill for and receive payment for a clinician who is new to the practice but not yet contracted or credentialed. We looked at one possible billing option of locum tenens arrangements. Now let’s look at how reciprocal billing works, and also examine ways to have providers provide service while awaiting contracting and credentialing.

 

Reciprocal Billing Arrangements

Reciprocal Billing Definition: A reciprocal billing arrangement is an agreement between physicians to cover each other’s practice when the regular physician is absent. This is usually an informal arrangement, and is not required to be in writing.

 

Medicare

Services may be submitted under a reciprocal arrangement if all of the following criteria are met:

  • The regular physician is unavailable to provide the services
  • The patient has arranged or seeks to receive care from the regular physician
  • The substitute physician does not provide services to the beneficiary over a continuous period of more than 60 days
  • The regular physician submits the claim with a Q5 modifier with each service (CPT) code

Reciprocal billing is another option for urgent cares if locum tenens arrangements are unavailable or are no longer an option. Similar to locum tenens, reciprocal billing arrangements cannot extend past 60 days. These stop-gap measures are meant to be a temporary solution, and Medicare assumes your clinic is working toward employing regular credentialed and contracted physicians to provide services.

 

Commercial Insurance Carriers

Verify with your contracted health plans to make sure you are following your contract and billing policies for reciprocal billing. If you do not know what is required by a specific payer, again, it is a good rule of thumb to follow Medicare policy.

 

Non-credentialed Provider Billing Criteria:

Locum Tenens Billing Medicare

Commercial Insurance

Not allowed for newly employed physicians

Varies by plan and by region – know your contract!

A locum physician with an NPI number may fill-in for 60 consecutive days. This means that even if the absent physician had a part time schedule (M-W-F), the 60 days counts all days during that period, not just the worked days

May follow own rules:· may require all providers (physicians, NPs, and PAs) to be fully credentialed before billing· may only require physicians and mid-levels to bill under practice or supervising physician

Mid-levels cannot
be used as locums

May follow
Medicare rules

Use modifier Q6 on claims

Reciprocal Billing

Generally the same
rules apply as for
locum physicians

Varies by plan
and by region – know
your contract!

Use modifier Q5 on claims

 

Tips for Utilizing Non-credentialed Providers

If neither locum tenens nor reciprocal billing arrangements are a solution for your practice’s billing needs, don’t lose heart. There are some options to help fill the gaps as your providers gain their proper credentials. Here are a few quick ideas that might help your urgent care:

  • Always, always know your health plan contracts well—and understand the best way to bill for non-credentialed physicians (so no violation and potential lost contract occurs)
  • Have non-credentialed providers see only self-pay patients
  • Have non-credentialed providers do sports physicals, occ med services, and other types of services that do not require credentialing
  • If commercial insurance allows some levels of staff to be non-credentialed, schedule more visits to those non-credentialed staff to help with workload until they receive their credentials
  • Work with patients who see a non-credentialed provider (out of network) so a payment plan or some other option can be utilized.
  • Start credentialing physicians right away (even while in the interview phase) so by hire date their credentialing is in motion and hopefully completed

 

A Last Word on Non-credentialed Provider Billing in Urgent Care

Non-credentialed provider billing will continue to grow as a topic and come under scrutiny. Due to the quick growth urgent care practices experience and turnover of physicians, it is important you know how to bill for non-credentialed providers when the need arises. You must understand your contracts with health plans and what their billing policies are regarding non-credentialed providers to avoid any potential violations. Work closely with billers and credentialing teams to ensure your urgent care knows exactly how to bill claims for non-credentialed physician services.

Do you use locum tenens or reciprocal billing at your urgent care? What advice do you have to share with others considering these type of billing arrangements? Share with our readers!

 

References

 

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