Provider Billing for The Non-credentialed & Non-contracted

Understanding provider billing for non-credentialed and non-contracted healthcare professionals can ensure your claims for service are accurate and help you avoid regulatory mistakes that could result in audits and, even worse, fines. It can be tricky to understand how to bill and receive payment for a clinician (physician or mid-level) who is new to your urgent care practice, but not credentialed or contracted with the health plans in which you participate. The following are the most likely reasons:

Reason #1: Permanent Full-time or Part-time Hire
As a practice grows, new providers are needed to manage heavier patient flow. Especially when this need is unexpected, a clinic owner may not have four to six months advance notice to fully credential a new clinician.

Reason #2: Temporary or Substitute Hire
A clinic may need to fill a role quickly due to the unexpected loss of a provider (i.e. termination or leave without notice), or temporarily when a clinician is absent due to illness, pregnancy, vacation, or other situations.

In these situations, practices often use a non-credentialed or non-contracted provider and ask their billing company if they can “bill for the new provider under the clinic name or under another doctor’s name.”

The answer is: it depends on the situation. Important to note “while commercial insurance carriers each have their own individual requirements, Medicare has its own set of rules separate from other insurance payers.”

Billing for Non-Credentialed Providers: Permanent Full-Time or Part-Time Hires

When it comes to accurate provider billing, you’ll need to pay close attention to your payer contracts in order to bill for non-credentialed and non-contracted providers correctly. If your new provider is not replacing anyone and if the health plan requires only credentialed clinicians provide services, you cannot bill for services rendered by that provider. A practice would be in violation of their contract with the health plan if they billed for services not provided by a credentialed clinician or by a credentialed substitute filling in for a previously credentialed provider (even if the contract is under the practice’s name). In some cases, the health plan will only require physicians be credentialed; in others, plans require all providers (physicians and mid-levels) be credentialed and tied to the contract.

On the other hand, you can bill under clinic name for new clinicians if the health plan does not require individual credentialing. In those cases, most health plans just need an updated roster of providers offering services under the clinic agreement.

Medicare Rule: Permanent full-time or part-time providers must be credentialed to bill for Medicare.

BLOG: Learn what should be included in your billing SOP for a healthier RCM >>

Billing For Non-Credentialed Providers: Temporary or Substitute Hire

In the second situation, the loss of a provider or if a provider fills in for a temporarily absent provider, the answer is more complicated. Let’s look at the two billing options available for non-credentialed providers in this circumstance—locum tenens arrangements and reciprocal billing arrangements.

Locum Tenens Arrangements

Locum Tenens Definition: A locum tenens is considered a substitute physician, who is only intended to fill in for an absent physician and does not plan to join the urgent care practice. Locum physicians may only practice and bill for 60 days.

Commercial Insurance Carriers

Locum physician services can be billed under the NPI of the doctor absent, with the Q6 modifier (service provided by a locum physician) added to each CPT code on the claim. If the locum physician performs post-op services in the global period—the substitute services do not need to be identified on the claim. Practices must maintain a record of patients seen by the locum physician (including the locum’s NPI), and this listing should be made available to commercial insurance carriers if needed.

The on-staff physician compensates the locum physician on a similar fee-for-visit or per-diem basis. The identification of the locum is mostly used for auditing, to confirm provided services—and not for payment purposes. Non-coverage notifications should be given in the on-staff physician’s name.

Medicare Rule for Locum Tenens

Medicare’s requirement is that an on-staff physician can bill and receive payment (when assignment is accepted) for a substitute physician’s services as though the on-staff physician performed them. If you have an on-staff physician who has left your practice and is unable to provide services, locum tenens billing may also be used. The Q6 modifier must also be added to each CPT code on the claim.

This Medicare rule applies to on-staff physicians and cannot be used for mid-levels. A 60-day consecutive limit applies for each locum physician—beginning from the first patient seen (even if patients aren’t seen certain days when a physician is on vacation, has days off, etc.). After the 60-day limit expires, an urgent care clinic may no longer bill for that locum physician. If services still are needed after this time, the practice must employ a different locum physician. New on-staff physician hires cannot be considered locum physicians.

RECIPROCAL BILLING ARRANGEMENTS

Now let’s look at how reciprocal billing works and examine approved ways for clinicians to provide service while in the process of contracting and credentialling.

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 the following criteria are met:

• The regular physician is unavailable to provide the services.
• The patient has arranged or seeks to receive health 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 ” At a Glance:

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, OccMed 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 during 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?

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References

• Medicare Claims Processing Manual. The Centers for Medicare and Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf