Can You Bill for Non-Credentialed Providers?

I recently received the a question from a practice that is hiring a new doctor who has a license but is not fully credentialed on the all the panels that the other providers in the practice are. They wanted to know how to bill for AND receive payment from insurance plans for this doctor as an in-network provider. This new doctor will also be the only provider in the clinic while seeing patients there, so there would be no option for oversight from another provider.

We need to start by evaluating some specific situations.

The new doctor is going to be a full-time or part-time permanent hire.

  • Medicare:

  • Doctors who are full or part-time hires must be credentialed by medicare in order to bill medicare for their services

  • Commercial Plans:

  • You should look at each individual contract. However, if the plan uses the same rule as Medicare, then you would only be able to bill for provider services once they are credentialed. Some commercial plans will allow a provider list to be updated and credentials the practice rather than the individual provider. If this is the case then all you would likely have to do would be to inform the payer of the new addition.

The new doctor is going to be a substitute provider for a TEMPORARY period. (Locum Tenens)

Locum tenens is a substitute physician who is providing care in the instance that the full-time physician is not seeing patients. This may be due to any reason for an absence. The typical period that the non-credentialed provider can see patients for is 60 days.

  • Medicare:

  • The credentialed physician is allowed to bill and receive payment for a substitute physician’s services as though the credentialed physician performed them.

  • Additionally, if there is a credentialed physician who has left your practice and is unable to provide services, locum tenens billing may also be used.

  • The practice will denote this by utilizing a Q6 modifier to each CPT code on the claim.

  • There is a 60 day consecutive limit applies for each locum physician

  • This starts with the first patient seen and continues every day even if patients aren’t seen certain days of the week or the locum physician has days off

  • After 60 days, the practice may no longer bill for that locum physician.

  • New physician hires cannot be considered locum physicians.

  • ​Commercial Plans:

  • Most follow similar rules as Medicare but consult your contract and or provider manuals for specific rules.

Additional considerations for Q6 modifiers:

  • The credentialed physician is unavailable to provide services to the patient

  • The locum tenens is paid for services on a per diem basis

  • The credentialed physician cannot be gone for less than 91

  • Does not apply to an expanding practice where there is a new physician at a different location, meaning there was not already a credentialed physician present to replace

For more information on Locum Tenens check out the CMS manual here.

Have a great week! ~ Chris