The COVID pandemic at once seems a long time ago and still very near. While mandatory masks and expanded healthcare protocols have diminished, in the world of credentialing and enrollment, attention to detail around certain items is still highly recommended.

1. HRSA is actively auditing how federal COVID dollars were spent. In reality, an audit of thirty health centers did not find much BUT like an IRS audit, they always find something. If your team became even a little lenient during COVID, time to tighten things back up.

2. The National Committee for Quality Assurance (NCQA) allowed payers to be significantly more liberal with credentialing and enrollment from Jan 2020 through Jun 2022. The catalyst for modification of policy, seen typically via a regional or federal 1135 waiver, is legitimate and expected when a disaster strikes. Jun 2022 was a year ago. Was your credentialing and enrollment team back on track by 1-Jul 2022 or still catching up?

3. Reciprocity state to state that allowed nearly all licensed healthcare providers the ability to practice across state lines was ubiquitous. This expanded policy included not just providers working at mobile sites or understaffed clinics but for telehealth. What is your team doing to have written protocols in place AND educate not just care delivery teams but schedulers, front desk, and RCM/billing staff to be on the same page? Seeking payment for a single encounter that is illegitimate (i.e., not permissible) would be considered a violation of the federal False Claims Act, carrying penalties starting at $13,500 per incident.

4. Does someone (anyone?) know the credentialing rules for your top payers (i.e., typically 3-5 payers make up 80%+ of a health center’s payments)? This includes but is not limited to Primary vs. Other Source Verification, and up to date certifications (e.g., ALS/BLS), active license (e.g., state, DEA, etc.). Everyone does not need to know how to do this, but someone needs to own it.

5. Lastly, some things never change. Locum Tenens is a federal Medicare policy that only works for Fee-For-Service and not PPS, meaning it is not legitimate for health centers. Chiropractic care is not covered by Medicare at health centers. The issue is the chiropractic manipulation CPT codes (i.e., 98940-98942) are not listed as “qualifying visits” under the Medicare PPS G Codes (i.e., G0466-G0471). And, as always, it is never permissible to bill an uncredentialed or unenrolled provider under another provider who is fully credentialed/enrolled.

In short, credentialing and enrollment complexities remain. If you have a seasoned and talented professional handling all elements of enrollment and credentialing that keeps you compliant with HRSA Compliance Manual Chapter 5, good for you. If not, find outside assistance. The team at PMG Credentialing would be glad to discuss how we might help. Contact us today.