In the words of Red Adair, “If you think it’s expensive to hire a professional to do the job, wait until you hire an amateur.”

Credentialing dictates how you bill. Do I bill as a group? Should I credential my nonphysician practitioners (NPP)? Which place of service (POS) should I bill with based on my contract? These are all important questions. Did you know that in April of this year, an urgent care chain reached a $22.5 million settlement with the U.S. Attorney’s office under the False Claims Act for submitting claims under the incorrect provider?

Professionals know the “rules” to keep your practice compliant and out of trouble. Here are a couple of the challenges that contracting/credentialing professionals face.

Can I Access this Network?

A credentialing expert can guide you on which payers you should contract with in your market and which contract is best for you.

A realization often shocking to both new and experienced urgent care groups is that of narrow or closed networks (meaning a major payer may not be accepting new providers into their network, or a health system has an exclusive agreement with payers). Clearly, this can be a deal breaker, depending on the payer.

For groups just entering a market it is imperative to do your homework or “due diligence” by early research with payers—ideally before committing to a lease and other costly infrastructure. This research should include the basic question of “Are you accepting new urgent care providers in your network in City, State?”

Some payers, like BCBS of Florida, publish this information on their website, but others may say you have to submit a formal inquiry or complete an application. The disconnect here is that the application process includes providing a tax ID, group NPI, physical address, and many other pieces of information you would not have if you were simply making an initial inquiry.

Anthem Blue Cross and Blue Shield of Virginia is one of the many payers that have implemented necessary requirements to comply with Virginia legislative House Bill (HB) 822, allowing new provider applicants under credentialing review for participation in provider networks to see members and retroactively receive payments if the provider is ultimately credentialed. Most payers adopting this policy are allowing providers with an existing executed contract to submit applications for new providers under this new policy. For providers entering into a new contract, the effective date will be determined based on the latter of the contract execution date or the completed credentialing application receipt date. For Anthem Blue Cross and Blue Shield and their affiliate HeatlhKeepers, Inc. in Virginia, this went into effect July 1, 2020.

Similarly, Washington state passed HB 2335. Health carriers there must process completed applications within 90 days of receipt. Effective June 1, 2020, the average response time may not exceed 60 days per RCW 48.43.755

There are a handful of other states with similar bills, and experts must stay current and modify credentialing processes accordingly.

Does This New Rule Apply to Me?

Often, guidance from payers’ websites announcing new requirements can be confusing and you might need to make a change quickly. This is often the case with the payer policies regarding NPPs. These articles often don’t state what product or contract type it applies to and can be as confusing to the payer as it is to the provider.

Take BCBS of Georgia for example. Some provider representatives are requiring practices to sign an amendment stipulating that they submit credentialing for NPPs. However, not all urgent cares in Georgia are receiving this amendment and not all provider representatives are requiring practices to sign it. This amendment requires NPPs to be credentialed and to begin billing all claims under their individual National Provider Identifier (NPI), meaning that the practices that sign this amendment are agreeing to a 15% discount in reimbursement.

Practices in Georgia began to submit NPP credentialing applications and found that if they had not signed the amendment described above, the NPP credentialing applications came back denied. Instead, they have been instructed to submit a Provider Maintenance Form for NPPs.

This brings up many questions. Are these amendments coming to all providers, and what will be the impact on providers that have yet to receive or sign these contract amendments? Does this apply to all products and contract types that BCBS offers? Will Anthem BCBS audit and request recoupment of payments? Is billing utilizing the SA modifier, which identifies the provider as an NPP, currently appropriate for all Georgia practices billing claims to Anthem BCBS? Will the Anthem BCBS of Georgia provider representatives begin to require all practices to sign these amendments? Are practices responsible to request these amendments in order to be in compliance?

A credentialing expert can navigate these questions for your practice because of their extensive experience working on behalf of many providers with lots of payers from which to draw knowledge and get to the correct answer.

There are a lot of moving pieces. One thing that is essential, however, is to ensure that whoever a clinic hires for contracting/credentialing has a good understanding of all of the requirements and the potential risks a clinic runs by not being current with what is happening in the industry.

Credentialing: Why Should I Hire a Professional?

Monte Sandler

Executive Vice President, Revenue Cycle Management of Experity (formerly DocuTAP and Practice Velocity ).
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