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Physician Credentialing Processes
Proper reimbursement for physician services relies upon a number of processes that require the
physician group to have effective policies and procedures with proper controls. These processes
include:
- Obtaining provider numbers for governmental carriers
- MCO credentialing
- Use of mid-level practitioners
- Decision about using locum tenems physicians
- Attention to MCO contracting specifics
- Use of physicians in training
- Choice of charting vehicles: written, dictated, or computer generated
- Attention to the proper documentation guidelines
Deficiencies in these processes can have a profound negative impact upon reimbursement and group
cash flow. BSA Healthcare can provide evaluation of these processes, with recommendations for correction of certain deficiencies discovered.
Frequently Asked Questions
Why is it so important to obtain timely provider numbers?
All governmental, and some commercial, third party carriers require individual provider numbers
in order for a claim to be submitted. The provider number must always be from the physician or
physician extender providing the services. The nature of emergency medicine lends itself to frequent
turn-around of new providers. The EP group must have an efficient mechanism to obtain all paperwork
necessary from the provider, and submit this completed information in a timely fashion to the carrier.
Many carriers have filing limits that disallow late submission of claims, causing non-payment when
the procurement of a provider number is delayed. Even worse, some carriers do not allow retroactive
claims payment prior to the date a provider number is issued. In these situations, the provider number
must be obtained prior to giving patient care since payment for this service will be denied.
Does the physician group need to obtain provider numbers for PAs and NPs?
Yes. This area has seen increased compliance enforcement in the last few years. Many carriers,
especially Medicare, require that the Evaluation and Management (E/M) code on the claim be
commensurate with the exam and decision-making performed by the provider of service. It is not
acceptable to bill an E/M code under the supervising physician's provider number if that physician
has not provided an exam with documentation consistent with the E/M code chosen.
Should the physician group sign every HMO contract, as is, due to concerns of angering the
hospital administration?
Usually, the answer is no. Rarely are there political situations where little negotiation is condoned.
These are the exceptions. There are multiple clauses dealing with credentialing, holdbacks, recoupments,
timely filing limits, definition of covered services, and basic payment rates that require close scrutiny.
Indeed, many paragraphs of HMO contracts have nothing to do with the practice of Emergency Medicine. If
negotiations are handled professionally, it is rare that the EP group will encounter undue resistance from
the hospital.
BSA Healthcare Services
EMERGENCY MEDICINE & PHYSICIAN SPECIALTY SERVICES
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