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New Credentialed Providers

Rochelle Garcia 3 years ago in Staff Module updated by Richard Sethre, Psy.D., L.P. 3 years ago 14

Hello,


Does anyone know what to do when you have new licensed provider that is not yet credentialed with all the insurance companies your agencies bill for? Do you still bill for those payers with the supervisor? And how do I set that up in Procentive so that staff can bill to some payers but not all? Thanks

The title for this question probably should be, "New Licensed, But Uncredentialed, Providers."  It also appears that there are really two questions involved: 

1. What happens when an unlicensed therapist providing services under supervision becomes licensed to practice independently? Most insurance companies require that the provider be credentialed once they become licensed. In other words, once they become licensed, most insurance companies will not reimburse under the supervisor, and will expect the newly licensed professional to obtain their own credentialing. The insurance company may or may not credential the newly licensed provider; just because someone has been providing services under supervision does not categorically guarantee that the insurance company will want to credential them. Therefore, the recommended practice is to submit a credentialing request immediately after the new license is issued (you could submit it before, but then you would not have a license #, which is necessary to process a credentialing application).  Some insurance companies may allow "continuity of care"  payment until the credentialing request is completed. It would be advisable to contact each insurance company to find out their policy on the situation. Some insurance companies have been known to be sticklers about not paying for services provided by non-credentialed licensed providers. Some are more understanding about situation and will allow payment until the credentialing process is completed-with the understanding that the newly licensed provider still may not be credentialed.

2. The question about how to set up a staff account in Procentive to bill some payers, but not all, probably would be best handled by submitting a ticket to Procentive, I think, unless someone from the user community is savvy about this and able to respond. 

When a therapist gets licensed, first  you go to the Staff module>Role>Clear the Supervisor fields. (While you are here you might as well fill in both Credential fields and then go to the Billing tab and fill in the NPI field). 


Second you go to each Payer in the Payer module that the newly licensed therapist has clients for and create a supervision rule.  Go to Rates>Staff> Add the newly licensed as a staff member, add the billing supervisor, change Sup.Req to YES, Change Use Supervisor NPI to YES. Save. 


As the newly licensed becomes credentialed with each insurance company, go to back to that Payer in the Payer module and delete the supervision rule.  

These steps allow for a newly licensed to immediately see fee-for-service clients without supervision but still be supervised for insurance companies until one by one they become credentialed.

Greetings to StechC and the rest of the user group interested in this discussion.  

StephC recommended a process that enables a billing service to bill for newly licensed therapists "without supervision but still be supervised for insurance companies" unit they are credentialed.  Frankly, I would be very concerned about using a process that sounds like an end run on the insurance company's credentialing policies - and your contact to follow these policies.  In other words - to be blunt - billing for a therapist who is licensed to practice independently with a CPT code that indicates that they are not licensed and practicing under supervision COULD be viewed as billing fraud by the insurance company, if they want to play hardball. I would highly, highly recommend confirming that this billing practice is acceptable by calling the insurance company. 

 I got my process directly from Procentive and then verified with my insurance companies. Thanks. 


Verifying with the insurance companies is, I think, crucial. As others in the user group have noted, some insurance companies may not - at least retroactively - authorize this billing arrangement.

Rochelle,


Speaking from VERY painful experience, BCBS MN does NOT pay during the credentialing process.  We had a newly-licensed provider who had submitted credentialing application and continued to see an established client.  Once credentialed, BCBS would not pay and all our appeals were denied.  State insurance is better.

Are you still within the time frame to go back and bill under the supervisors NPI for the period of time between the provider submitting the application and approval?  They should pay as long as the original claims were sent within the timely filing window.  Worth looking into......

+1

This was back in 2015.  And you know how short the BCBS timely filing window is...

We have not had a problem being paid with most insurance; however, there are a couple (Mayo Clinic, Medica) that do not accept clinical trainees--all providers must be licensed, contracted, and credentialed in order to bill. 


We bill BCBS, MA, B+, Health Partners, Preferred One, South Country Health Alliance, and Ucare all using a supervisors NPI and have never had any issues being reimbursed-- as long as we were billing under  a contracted/credentialed supervisor and using the appropriate modifier.  This can continue until the credentialing process is complete for the newly licensed provider.

HealthPartners is the same. We change them to pro bono while staff is getting credentialed. And we don't take any new HealthPartners clients until they are credentialed. I will be adding BCBS to that list. Thank you, Sheryl!

Sarah---see my comment above.  BCBS will pay on non-licensed/ non-credentialed provider as long as they have a contracted/credentialed billing supervisor. 

Greetings to Laura and the rest of the user group interested in this discussion:

I think that, if I understand correctly, the original question was not how to obtain payment for unlicensed trainees practicing under supervision.  Rather, the question whether you can bill for a newly licensed professional, now licensed to practice independently, by falsely claiming that they are sill unlicensed and practicing under supervision - which could be, potentially, billing fraud. 

Good to know. Thank you, both!