Wiki Continuous Billing of non-credentialed physician

[CorinneM]

We have ppl in the MCR credentialing process at this time. They are not yet credentialed but their claims are continuously being sent so that we are not holding claims. I thought there was something out there about repeatedly sending claims that you know won't be paid? I may be having this confused with something else but does anything about this sound familiar to anyone? TIA

 

[thomas7331]

Yes, repeated unnecessary submission of claims is addressed by the OIG and falls under the category of 'abuse' because it can be costly and burdensome for the payers to process all the claims and can also trigger payment errors. Most likely in the case of a provider not being credentialed, the claims are not actually even getting to the payers because they reject up front or in the clearinghouse and never make it into the payer systems, and depending on the volume may not really be having much impact, but it's still not the correct way to manage the workload.

 

[avon4117]

i would place those claims on hold until the credentialing process is complete...medicare will retro back to cover those dates

 

[snahcee]

i would place those claims on hold until the credentialing process is complete...medicare will retro back to cover those dates

Can you say more about this? My understanding is that a provider should not be touching lives of those payers that have yet to credential. It's kind of the point of credentialing. If the dates of service pre-date the approval date, how can those claims be justified?

Thanks!!

 

[csperoni]

The physician can certainly provide whatever service you want. The issue is whether or not you will get paid by the insurance. Our local Medicare carrier will make the effective date the date of the received completed application. Other carriers will make the effective date the date they approved the application. Many will backdate. In fact, we recently had 18 months of claims reprocessed by a carrier who backdated an effective date to March 1, 2016. You need to know each carrier's policies as to which patients the new provider should be seeing yet. Typically, we hold the claims until credentialed, or until we are concerned about timely filing guidelines.