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Medicare Changes Enrollment Guidelines From 30 days to 60 days

Author: Leigh Polk, PSA Marketing and Support Services Director
Posted: 28 July 2012
Copyright: (c) 2012, PathologyOutlines.com, Inc.

Beginning May 14, 2012, after considerable pressure from HBMA and other organizations, Medicare will allow enrollment applications to be submitted 60 days in advance of the provider’s start date. This is good news for physicians and credentialing departments because Medicare can typically take 60-120 to process applications. For doctors moving to a new state, their new state medical license must still be issued before the Medicare application can be submitted.

To comply with the current requirements of regulatory governmental agencies and insurance providers, credentialing has taken on a new dimension. Credentialing is no longer a part-time assignment; it requires the full-time attention of trained credentialing specialists. This is why many billing providers charge an extra fee for the service (PSA provides credentialing to our clients at no additional charge).

PSA’s credentialing department works with billing clients to ensure physician enrollment with payors is accurate and up-to-date. The fundamental purpose of credentialing is to ensure that physicians meet minimum requirements as a part of risk management. Negligent credentialing of new and existing physicians within a practice can hold insurance plans liable for exposing an insured patient to an unqualified physician.

PSA clients are continually hiring new physicians or replacing retiring physicians. Therefore, PSA wanted to take this opportunity to clarify some common misconceptions regarding new physician credentialing which are listed below.

Clarifying Common New Physician Credentialing Misconceptions

1. A practice can simply decide not to bill a payor until the credentialing process is complete, and encounter no payment issues: FALSE.
Most commercial payors assign an effective date when their process is complete – not when the provider joined the group. Therefore, if a practice decides to postpone billing until the credentialing process is complete, reimbursement may be based on out of network rates impacting both the practice and the patient.

2. Once a physician is credentialed for the first time, he/she is covered for any future changes: FALSE.
Most commercial payors and many government payors require re-credentialing on a regular schedule in ensure their database has up-to-date information. Failure to complete re-credentialing requests can lead to the termination of a provider’s billing privileges. All changes – i.e. TIN, practice name, location, etc. – must be relayed to all payors.

3. It is not necessary to notify PSA / the billing company when a new physician joins the group or prior to their start date: FALSE.
Advance notice of at least 60-90 days prior to the new physician start date will give the credentialing department the opportunity to notify as many payors as possible and hopefully complete most of the necessary updates prior to the physician’s start date. As previously mentioned, whenever there is a change in TIN for a physician, this must be relayed to all payors.

4. The credentialing process is not lengthy especially if the physician has been credentialed before: FALSE.
Medicare typically takes 60–120 days to process applications while Commercial Payors can take between 2 weeks to 6 months to process applications, depending on the physician’s current credentialed status. Timelines for credentialing are affected by many variables. For example, a physician just out of school/training and a physician moving from another state will take longer to credential than an established physician moving from one practice to another within the same state.

PSA specializes in pathology and clinical laboratory billing, marketing, and business support services. For questions related to this topic or to learn more about PSA, please visit www.PSAPath.com or contact Leigh Polk at 1-800-832-5270 ext. 2941 or lpolk@psapath.com.