By: Ray Jorgensen, Co-Founder, PMG Credentialing

Every health center seems to have provider vacancies to fill. Whether family practitioners, PAs, dentists, or behavioral health staff, provider shortage issues are commonplace. When a health center does fill a vacancy and that provider starts work, it can take months before s/he is fully enrolled with all the payers with which the heath center participates. How does your health center manage a new provider who is not fully enrolled? Here are some thoughts to consider.

1.      Don’t Bill Under Another Provider’s NPI. All too often a new provider has his/her services billed under the medical director or a provider who “signs the charts” of the new provider. The logical thought is, well, legitimate work was done, and documentation will prove that, so it is permissible to seek payer payment. The issue is most payers prohibit this practice. By submitting the claim under the NPI of the provider who did not do the work, the claim is illegitimate. The only risk-mitigating workaround is to get from a payer written permission to bill a new provider’s work under another already-enrolled provider’s NPI. Any other scenario could constitute an abusive billing practice or accusations of fraud.

2.      Strategically Schedule Patients. Since it is not OK to bill under another already-enrolled provider, consider scheduling patients where individual provider enrollment status is not relevant. Here are a few options:

• The most obvious example of this is for the new provider to see as many self-pay patients as possible.

• Another example is for him/her to provide “on call” phone support or work related to global billing like obstetrical care.

• If certain health center services are grant covered AND not billed to third party payers, these services would be another option.

• Lastly, consider leasing the provider to a facility (e.g., nursing home, hospital, or urgent care). The health center could contract with the facility to periodically provide them staff with the health center (not the provider) being paid for the work. Those facilities would be billing under a facility claim format (i.e., ANSI 837-I) which requires the facility to be enrolled but not necessarily the individual provider. Obviously, this latter option takes some time and diligence including verification that the facility would over malpractice since those services, in most instances, are out of scope for FTCA coverage.

Key Takeaway: None of these activities result in the health center creating a claim to a third-party payer billed under an individual NPI.

3.      Maximize Services Billable via 837-I. A final consideration is to make certain the newly hired provider sees patients for whom third party claims would be billed via an 837-I; i.e., an institutional claim or the UB-04. The rationale is this institutional claim format uses a group NPI vs. an individual. Any employed provider whether 1099 or W-2 can be billed under that group NPI. While a health center awaits a newly hired provider to be fully enrolled, this is great option as many Medicaid and all straight Medicare claims are billed via 837-I to obtain encounter rate payment. Some Managed Medicaid and some Medicare Advantage plans also pay via 837-I to obtain encounter rate. Check with the revenue cycle management provider or billing team to learn which health plans afford this option to know how to optimize the schedule of a newly hired provider.

Newly hired provider billing will continue to be challenging. With a little effort and advanced planning around schedule management, claim/billing liabilities can be eliminated, and enough income generated during the enrollment process to offset this new staff person’s salary/benefit expense. Make time to consider what works best for your health center team.

And, if all else fails, contact PMG Credentialing to see how our team of experts can help expedite and maximize your health center’s credentialing and enrollment.