By: Ray Jorgensen, Co-Founder, PMG Credentialing

It is a common conundrum. For more than two decades we owned a revenue cycle management (i.e., RCM, a.k.a. billing) company. Team members would find out a client had a new provider most often when a claim was received with a provider’s name that no one knew. It was maddening, common-place, and incredibly avoidable. In short, we have always advised RCM/billing folk to chat with the HR department at least bi-weekly to learn about new hires. Today it is as simple as an email reminder (which you can even automate) to ask HR if a new doc, NP, PA, CNM, etc. has been hired. Remember also, if the provider is new to the area only Medicare and most Medicaid programs will retroactively enroll that provider and usually only back to the date of application submission.

So, people ask, when should credentialing/enrollment begin? We have always suggested enrollment/credentialing paperwork go out with the offer letter AND there be language in the offer letter or employment contract that obligates the new provider to be enrolled with Medicare, Medicaid, and the top payers (i.e., payers that generate 80+% of monthly income for your health center) no later than the first of the six month of employment. Even that timeline sounds long but realistically, payer enrollment and facility credentialing… if all goes well… is at least 60 and often 120 days. Add a pandemic, staff shortages (for you and the payers), mistakes on the application, etc. and it can take much longer.

Don’t get me wrong, keeping a stack of ready to go documents for new hires takes time to prepare.  Are applications current? Any new addendums for this or that payer? Who owns the check-in with HR about new hires never mind hounding the newbie about returning his/her thoroughly completed paperwork and supporting documentation (e.g., DEA and state license info, explanation of any med-malpractice issues, PSV data, etc.)? However, once it is gathered a quick check with top payers about the current status of forms and the other aforementioned items mitigates longer term headaches resulting from having a provider without a billable NPI. 

But isn’t it OK to just bill under the medical director or another provider with similar credentials (e.g., bill a new NP under a fully credentialed/enrolled NP)? If billing an 837-P (i.e., electronic version of the paper CMS-1500) or an 837-D (i.e., electronic version of a paper dental claim) the individual provider NPI is required. Period. Falsifying the rendering provider is at best a clear-cut contractual violation and with government programs potentially subject to criminal prosecution. This is no joke and using the logic of “everyone does it” won’t bode well before an OIG auditor or a jury of your peers.

Remember, if billing the 837-I (i.e., electronic version of the paper UB-04) the NPI used is the facility. At a health center this could mean using one facility NPI for all locations or having a unique facility NPI for each individual clinic. Since 837-I billing is under the group NPI, the new hire would only need to be a contracted employee (i.e., W-2 or 1099) and, literally on day one, 837-I claims may be submitted for services rendered by this otherwise uncredentialed and unenrolled individual. Be cautious as it can get tricky. For example, while a Medicare beneficiary seen by a new staff provider not yet enrolled with all payers would be permitted to bill Medicare an 837-I for say an office visit and/or procedure, s/he could not have a claim go to Medicare on a 837-P for related diagnostic studies that require the new provider’s individual NPI to be linked to the health center’s EIN/TIN. In order for the 837-P to be submitted under the new providers’ NPI, completion and Medicare affirmation of acceptance of an 855-R (used to reassign payment/benefits to the employer) must be securely on file. 

None of this is necessarily simple. For more than two decades I’ve raised a toast to the complexities of healthcare that have fed, housed, and educated my children, bride, and me. Health centers can do this alone… but really… is this a core health center competency? I think not. Contact PMG Credentialing or find a credentialing consultant to make certain your health center enrollment and credentialing processes are top tier and not creating avoidable risk. You will be glad you did.