In the healthcare industry, everything works in a specific order, following all patient health protocols. Any type of discrepancy or negligence can lead to tremendous loss. Therefore, it is necessary to verify the legitimacy of all providers’ credentials before enrolling them in health insurance plans.
Healthcare providers first undergo medical credentialing to get authorization to practice medicine. They provide medical services to patients and get reimbursed for their services. However, insurance companies only reimburse physicians who have completed the payer credentialing process.
However, whether providers can see patients before payer credentialing is done arises. This article will discuss the risks of seeing patients before payer credentialing and answer all relevant questions.
What are the Risks of seeing Patients before Credentialing?
There are some defined protocols in the healthcare industry, and it is necessary to follow those to maintain standards and avoid profound implications. Seeing patients before payer credentialing can lead to the following potential issues:
1. Reimbursement Denial
Insurance companies have strict rules regarding credentialing and reimbursement policies, and they only pay once you are credentialed. Even if you have submitted the credentialing application but not received authorization, you can get reimbursed for the services you provide.
2. Out-Of-Pocket Costs For Patients
Nearly all patients have insurance coverage and want to get in-service payment. If your provider is not credentialed, patients are forced to pay out-of-pocket, leading to their financial loss. Patients’ dissatisfaction, potential loss of patients, and a damaged provider’s reputation are possible outcomes.
3. Compliance And Liability Issues
Seeing patients without payer credentialing being done leads is risky, and providers may face legal issues. If something goes wrong while providing medical services, providers do not have any legal protection and have to face malpractice claims. Liability issues can even result in the termination of their license. There is no specific law, but it is advised not to see patients without credentials.
Things to do while waiting for Credentialing
Payer credentialing is a lengthy process that even takes months to complete. Medical providers can’t remain out of practice this whole time, and there are few things he can do while waiting for authorization from insurance companies.
- Some health insurance companies allow providers to bill on their NPI numbers under the supervision of senior physicians. Providers need to confirm with the insurance companies whether they allow supervision billing. If so, they can start rendering medical services and get reimbursed.
- Another good option is seeing patients covered by the Medicare program, as Medicare allows reto-billing up to 30 days from when the application for registration is submitted to the Medicare Administrative Contractor (MAC). Therefore, work in an old-fashioned way, write an application to the MCA, and start rendering medical services. Providers are billed after getting registered with Medicare and receiving a PTAN number, but it is still better than not doing anything.
- You can also see Medicaid covered patients but each state has different rules regarding the retro-billing for Medicaid. If your state allows reto-billing then, you can consider this option as well.
- Providers can also see patients on a cash basis, but patients don’t like this method, and it also has serious outcomes in case of malpractice claims.
- Providers can also work on building their reputation while waiting for the credentialing process. They can collaborate with media teams and enhance advertisement projects regarding their medical services and expertise.
Conclusion
Payer credentialing is a long process, and it takes about three to six months to complete. Providers are not billed for the services they offer during the waiting time. Can providers see patients before payer credentialing is done? Yes, it is possible to see patients, but there are some risks that should be kept under consideration.
Legal, financial, and ethical implications advise not to see patients before credentialing. If providers still want to practice medicine during the waiting time, then they can see patients under the supervision privilege provided by some insurance companies. Enroll with Medicare and Medicaid programs and see patients on a cash or free basis for continuously practicing before the payer credentialing.
FAQ - People Also Asks
Credentialing is done by submitting an application along with proofs of medical education, certifications, licenses, training and work history. These credentials are verified by the credentialing committee and they give a final report about the legitimacy of documents. Then, authorization is granted to start rendering medical services and billing.
Legally, it is unacceptable to bill under another provider. If a non-credentialed provider bills under another provider’s NPI number, his utilization rate will increase, alarming the payer that something is wrong and needs to be checked.
It takes 60-90 days to get credentialed with Medicare. The provider needs to submit an application through the Provider Enrollment, Chain, and Ownership System (PECOS). Several factors, such as incorrect or missed information and high application volume, can extend the processing duration.
There are no specific laws that restrain providers from seeing patients before credentialing. Non-credentialed providers can see patients, but risks are always present. Without credentialing, they can’t be billed for services and have no legal protections.