CHC Credentialing… Great Opportunities and Frightening Liabilities

Categories: Billing, CHC, PMG Insights Blog

August 15, 2016

Credentialing one way, Violation anotherMany CHCs struggle to maximize reimbursement. Transition from cost based to PPS rates, understanding Medicare G codes, ACA programs advocating APM and expansion of services via managed Medicaid plans… the complexities of healthcare, especially for CHCS, seems inexhaustible. Getting paid starts with having a National Provider Identifier (NPI) for all appropriate persons and entities. Most CHC billers and some CFO folks understand needing a facility NPI for each location and individual NPIs for core providers. However, too few understand potential pitfalls and too many think certain “common” practices are permissible when they are fraught with potential liability.

Here are a few quick thoughts to consider around credentialing… or more aptly, enrollment.

Credentialing vs. Enrollment

Enrollment is the process of getting providers or facilities (e.g., CHC clinics) into participation status with payers. Being a participating provider/clinic is essential to see a payer’s or plan’s members and be paid an optimal fee schedule. Credentialing is the actual assignment of participating provider status after the provider/clinic credentials have been thoroughly vetted by each payer. Enrollment is the process of submitting application to credentialing committees at payers. So, enrollment processes results in credentialing of providers with payers.

Individual vs. Facility (Clinic) NPIs

Nearly all payers require a unique NPI for all CHC core providers. Remember this means not just doctors but most mid-levels or non-physicians (e.g., physician assistant). At CHCs, Medicare Part A (think PPS and G codes) are billed via the ANSI 837-I (institutional) vs. Part B (think fee-for-service for diagnostics and non clinic encounter work) via the 837-P (professional). The 837-I is a group number and as such ANY employed providers (even those starting today) may have PPS visits billed under the group NPI. However, Part B… and nearly all other payers… require the 837-P necessitating the individual provider to be credentialed with each payer. This means until the provider is fully credentialed your CHC is unable to even submit claims to those payers requiring 837-P claim format.

Billing New Providers Under Other Staff NPIs

Hiring new core providers is expensive and getting paid as quickly as possible for work they provide to patients is obviously quite desirable. PMG finds too many CHCs billing work rendered by the new core provider under the medical director or other already credentialed staff. Unless your CHC has a statement in writing from a respective payer which allows billing under another provider’s NPI, this is patently illegal. It is fraud with a capital “F.” The preceding example of Part A Medicare is an exception but don’t fall into the trap of “everyone does it” or “we have to get paid” because you will lose this battle. One Qui Tam phone call or claim inquiry from a payer could result in fines/penalties well exceeding any lost dollars from not getting paid for the first months the new provider is employed. A good strategy is to have new providers see cash patients, grant funded patients, and Medicare Part A… no individual credentialing necessary for these payers. This is not always possible but will mitigate loss and risk.

Medicare Exclusion List

Most CHC leadership remain blissfully unaware of pitfalls resulting from not regularly (think at least quarterly but preferably monthly) reviewing the Medicare Exclusion List for ALL staff but especially for providers. There are companies that can manage this for a CHC but a quick check of the OIG site is pretty easy (https://oig.hhs.gov/exclusions/). Remember, it is against the law to bill a government payer while employing an excluded person. A person could be on the exclusion list because they worked at a facility that had been penalized or a provider for something as seemingly innocuous as not repaying a federal student loan. Check the list. Avoid this easily avoidable issue.

Non-physician Practitioners (NPPs)

NPPs is the term CMS using to define nurse practitioners, midwives, physician assistants, certified diabetic educators, and the host of other clinical staff who are able to be assigned NPI AND be credentialed by CMS for individual payment. Most third party payers (but not all) mirror CMS policy around credentialing. Certain payers (e.g., Aetna) has historically not credentialed NPPs. However, most other payers do. Not credentialing NPPs when a payer requires it creates liability for your CHC. Some CHCs have told PMG they don’t credential NPPs because they get paid more money for submitting their work under a doctor. The “F” word was mentioned earlier and this overtly deceptive practice of seeking more money than warranted is at worst an abusive billing practice and at worst, a fraudulent act. Bottom line: if a payer credentials a NPP, get them credentialed and use their NPI for submission to all possible payers.

Third-Party Enrollment/Credentialing

Call it enrollment or credentialing but this stuff can be vexing. Hiring an outside firm to manage enrollment/credentialing may seem like a luxury. In truth, the peace of mind for getting it done right (never mind an objective third party to vet internal processes) is priceless. Plus the ROI for the price of enrollment/credentialing service is usually equal to 10-12 paid visits for the newly enrolled/credentialed provider. In other words, national UDS data shows CHCs make about $125 per visit. Only 10-12 visits paid equals $1,250-$1,500. In other words, a service costing around this much money, pays for itself within 10-12 visits.

Regardless of the cost-effective services available, we expect too many “pennywise and pound foolish” CHC leaders will continue to find themselves behind the eight ball when an investigation or accusation arises around credentialing/enrollment. Avoid penalties, maximize income, and know your CHC does it right by vetting the processes internally or hiring an outside firm to assure optimal performance and compliance.