Each payor anticipates that the practice will submit a medical claim that appropriately identifies the doctor who delivered the service. Similar to duplicating a friend’s test, invoicing a claim under Provider B’s name when Provider A visited the patient is unethical. When a practice hires a doctor whose credentialing is pending, it impacts its capacity to bill for medical care. So, billing for non credentialed physicians is an important thing to consider in these scenarios.

Why do non-credentialed physicians often find themselves in trouble? Their lack of understanding of the regulations is the first factor. Instead of going directly to the source, many physicians rely on word-of-mouth and subscribe to the maxim that whatever is done must be correct. Further, medical credentialing services can help providers grow their network.

Billing for Non Credentialed Physicians

In particular, every entry in electronic medical data is time- and date-stamped and associated with a specific user. Therefore, if a doctor did truly assist with the encounter, he should detail everything that was done on the record and verify the entry. However, a practice may hire non-credentialed physicians in the following settings:

Incident-to Billing

In “incident to” billing for Medicare beneficiaries, CMS will pay 100% of the physician claim even if an NPP visits the patient. The NPP is carrying out an order from the MD while a doctor is present on the premises during the service; this is an incident-to scenario in which the doctor has personally treated the patient for the specific medical condition and has formed the diagnosis and treatment plan.The practice must submit claims using the doctor’s NPI to ensure reimbursement, as the doctor’s involvement in the patient’s treatment remains active.

Locum Tenens Arrangements

The term “locum tenens” refers to physicians who work in a hospital under temporary employment arrangements. Locums are often used for short-term staffing needs, such as when an inpatient physician is on vacation or leaves for another assignment. Locum tenens arrangements are an effective way to supplement your income and provide continuity to patients. The key is ensuring you get reimbursed for your work.

Reciprocal Billing Arrangements

A reciprocal billing arrangement is an agreement between two parties that allows them to receive payment after they have performed certain services on behalf of one another. This can be quite challenging if you are a non-credentialed physician seeking reimbursement for services provided for another group. You must ensure that you are billing accurately and that your patient’s insurance company understands the benefits they will cover.

Important to Remember:

The “incident to,” “locum tenens,” and “reciprocal billing” standards are Medicare guidelines and might not apply in the context of billing for private payers. This implies that it’s vital for doctors to comprehend the terms of their health plan contracts, including what they permit and disallow

Non Credentialed Physician CPT Codes and Modifiers

In the United States, out-of-group and non-credentialed physicians are usually paid using a fee-for-service model. To bill for services provided by non-credentialed physicians, you must use CPT codes with modifiers designed explicitly for this purpose.

A credential service provider must submit each service’s claim with a Q5 modifier in a locum tenens setting. Each CPT code on the claim will be offered after adding the Q6 modifier. The medical billing process can be daunting for those unfamiliar with the rules of billing for non credentialed physicians. No universal guidelines can help physicians who want to work as contractors with different healthcare agencies.

How can Medical Billing Services Providers Help?

As a healthcare professional, you must understand the billing for non-credentialed physicians is quite complicated, and private insurance providers do not cater to them. Several medical billing services provide credentialing services too. They can help non-credentialed physicians manage their healthcare claims and get credentialed. They may assist you with the following procedures, too, along with medical billing:

• Credentialing and Contracting Process
• Enrollments and Revalidations with payors

Not sure where to find the right credentialing service provider? Transcure is renowned for providing medical credentialing services for non-credentialed physicians. We streamline billing for non credentialed physicians to get into contracts with different payers. We provide comprehensive solutions for both solo and group practices.