Billing in the healthcare sector can be complex, especially when dealing with non-credentialed providers. Understanding whether a non-credentialed provider can bill under another provider is crucial to avoid compliance issues and potential revenue loss. In this blog, we’ll delve into the intricacies of this topic, breaking it down step by step for clarity and practical application.

1. What Does it Mean to Be Credentialed?

Before exploring the billing aspect, it’s essential to understand credentialing.

Credentialing verifies a provider’s qualifications, such as education, certifications, and professional history. This ensures they meet industry standards and are eligible to practice and bill for services.

Credentialing is vital in provider enrollment with insurance companies, enabling direct reimbursement for their services.

2. Who is Considered a Non-Credentialed Provider?

A non-credentialed provider is someone who has not completed the credentialing process with insurers or regulatory bodies.

1. This could include newly hired providers who are in the process of credentialing.
2. Providers offering specialized services but not enrolled in specific insurance networks.
3. Those who have yet to renew or update their credentials.

Non-credentialed providers often face challenges in billing directly for their services.

3. Can a Non-Credentialed Provider Bill Under Another Provider?

The short answer is: that it depends on the situation and the payer’s policies.

Some payers allow “incident-to” billing or other arrangements where non-credentialed providers can bill under the supervising provider’s credentials. However, strict guidelines govern this process.

Understanding these policies can help avoid claims denials or legal complications.

4. What is “Incident-To” Billing?

“Incident-to” billing is a common method for billing services provided by non-credentialed providers under a supervising provider.

1. It applies to outpatient services supervised by a credentialed physician.
2. The supervising provider must be actively involved in the patient’s care plan.
3. Services must meet specific payer requirements to qualify.

Incident-to-billing allows healthcare organizations to maximize reimbursements while ensuring compliance.

5. Key Requirements for Incident-To Billing 

Incident-to-billing isn’t a loophole; it comes with strict requirements.

1. Direct Supervision: The credentialed provider must be physically present in the office during the service.
2. Established Care Plan: The service must follow a treatment plan established by the supervising provider.
3. Covered Services: Only specific services qualify for incident-to billing.

Failure to meet these requirements can lead to denied claims or penalties.

6. Exceptions to the Rule 

Certain scenarios allow non-credentialed providers to bill without incident-to-arrangements.

For example, Medicare permits billing for some services by non-credentialed providers under a “locum tenens” arrangement when a credentialed provider is unavailable. Similarly, state Medicaid programs may have unique policies regarding non-credentialed providers.

Understanding these exceptions can broaden your billing options.

7. Risks of Billing Under Another Provider 

While incident-to-billing is legal, improperly billing under another provider can lead to significant risks.

1. Claims Denials: Insurers may reject claims that don’t meet incident-to criteria.
2. Audits and Fines: Misrepresenting services can trigger audits and financial penalties.
3. Legal Consequences: In severe cases, improper billing could result in allegations of fraud.

To mitigate these risks, ensure strict adherence to payer guidelines.

8. Compliance Guidelines for Billing Practices

Compliance is the cornerstone of safe and legal billing practices.

1. Establish clear policies for incident-to-billing within your organization.
2. Train all providers and billing staff on payer-specific rules.
3. Use credentialing software to track the status of each provider’s credentials.

By prioritizing compliance, you can reduce errors and maintain trust with payers.

9. Steps to Credential a Non-Credentialed Provider

Credentialing non-credentialed providers can open doors to direct billing.

1. Gather Documentation: Collect licenses, certifications, and work history.
2. Submit Applications: Apply to insurance networks through platforms like CAQH ProView.
3. Follow-up: Monitor the status of credentialing applications to address delays.

Credentialing streamlines billing and expands revenue opportunities for healthcare organizations.

10. How Technology Simplifies Credentialing and Billing

Technology plays a critical role in managing credentialing and billing processes.

1. Credentialing software automates document collection and submission.
2. Billing platforms ensure compliance with incident-to and other payer-specific requirements.
3. Analytics tools track denials and identify patterns to improve billing accuracy.

Investing in the right technology can transform administrative tasks into efficient workflows.

11. Best Practices for Managing Non-Credentialed Providers

Managing non-credentialed providers effectively ensures seamless operations.

1. Plan Ahead: Begin credentialing for new hires as early as possible.
2. Develop Policies: Create clear guidelines for billing under another provider.
3. Communicate with Payers: Stay updated on changes in payer policies regarding non-credentialed providers.

These practices minimize disruptions and ensure compliance with industry standards.

12. Why Credentialing Matters for Long-Term Success

Credentialing is more than a billing requirement; it’s a foundation for trust and growth.

1. Credentialed providers enhance patient confidence and satisfaction.
2. Direct billing expands revenue streams and reduces administrative burden.
3. Compliance with credentialing standards protects your organization from legal risks.

Investing in a robust credentialing process benefits providers, patients, and healthcare organizations alike.

Conclusion

Can a non-credentialed provider bill under another provider? This depends on payer policies and compliance with guidelines like incident-to-billing. While there are pathways for non-credentialed providers to bill legally, the safest and most sustainable approach is to complete the credentialing process.

By following best practices, leveraging technology, and prioritizing compliance, healthcare organizations can confidently navigate billing challenges and ensure their operations remain efficient and trustworthy.