Optometry Coding & Billing Alert

Published on Mon Sep 01, 2008 PDF

Question: Our practice is expanding and we will soon have two new optometrists starting who are not yet credentialed with any of our insurance companies. Can we let these physicians see patients and then bill for those services?

Louisiana Subscriber

Answer: The answer depends on the carrier. Here's what you need to know to ensure you properly integrate these optometrists into your billing system:

Medicare: Medicare will allow you to hold your optometrists' claims from the date they apply for their Medicare provider numbers via the CMS 855 applications, and then file them once the optometrists receive their credentialing from Medicare. You can do this for all of your optometrists' Medicare services while they remain without credentials. Medicare will pay your claims retroactively from the date of the practice's new optometrist's 855 application. You should contact your carrier for details regarding how to do this.

Private payers: Check with the individual payer. Some non-Medicare payers may give you an effective date for when you can start billing. Most payers will not take claims from dates of service prior to the date when they approved the optometrist as a credentialed paneled participating physician with their plan.

Remember: You cannot bill services under another provider while you're waiting for the new optometrists' credentialing completion. There is no such thing as a physician billed "incident to" another physician. Billing one physician's services under another physician's NPI or identification is fraud, because you are identifying a service that the physician on the claim did not provide.

Try this: When a patient needs to see an optometrist before that optometrist is credentialed, you can take the private-pay/non-participating route, if the patient is willing to do it.

Be sure to allow your office plenty of time when trying to credential a new physician. The process can take 90 days or even longer, according to Medicare. Experts recommend that you initiate this process as far in advance of a new physician's starting date as you can. If you can act early, you'll have the necessary credentials in place when the optometrist starts seeing patients, and you won't have to worry about delayed payments.