Author Topic: who should be credentialed  (Read 3028 times)

desheba

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who should be credentialed
« on: April 18, 2013, 02:28:57 PM »
I have a question....if I have a client that owns a clinic and pays the doctor to treat patients in his clinic, should the clinic be credentialed or just the physician or both?  The clinic wants to get paid for the services the provider renders, and I want to make sure I cover all my bases.

Thanks,

RichardP

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Re: who should be credentialed
« Reply #1 on: April 18, 2013, 04:30:28 PM »
You seem to be presenting two separate issues, so I will address each of them.

I have a client that owns a clinic and pays the doctor to treat patients in his clinic ...

Who hired the doctor to work in the clinic?  That entity is the one who should be credentialed.  Billing would be done under the name of whoever hired the doctor.  So long as the hiring entity (therefore, the billing entity) is credentialed, it is irrelevant whether the doctor hired is credentialed.

The clinic wants to get paid for the services the provider renders ...

For this to be legal, the clinic must be the entity who hires the doctor doing the work, and bills for the work done in its own name.  In order for the clinic to be able to do this, certain state-imposed requirements must be met.  If the client/clinic are also treating Medicare patients, Federal-imposed requirements must be met.

For reasons such as this, you should not be giving any advice to anyone re. the question you just asked.  That is the sort of question only a health-care attorney who knows the requirements of your state and the CMS requirements should be addressing.

Billergirlnyc

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Re: who should be credentialed
« Reply #2 on: April 18, 2013, 06:01:06 PM »
Actually, it's not always true about it being irrelevant if a physician/practitioner working for a group is credentialed or not. Almost all commercial carriers will require a list of providers who work under the group on an ongoing basis, even if they don't require individual credentialing of them, because the group has been vetted. They want to know who will be seeing their members and will either want a copy of their license and or malpractice with that list, so it's a good idea to call and ensure what you need to do. This list and info is often required per the group's contract with said carrier.

In cases like say Medicare -- they'll let you send in an 855R to reassign benefits to the group, but if said practitioner/physician isn't in Medicare you have to send an 855I and 855R. <-- just used as an example.

Also, plenty of carriers STILL require to credential the individual provider even if they're going under the group and the group has been credentialed. Just like some commercial carriers won't credential groups or facilities but ONLY the individual provider UNDER the group's Tax ID. I can think of 5 plans that service the tristate area for say PT/OT that do this. There are tons of little nuances, just be sure you're clear about the requirements for EACH plan your client's clinic is in, so you don't run into any issues.
« Last Edit: April 18, 2013, 06:04:19 PM by Billergirlnyc »
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desheba

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Re: who should be credentialed
« Reply #3 on: April 18, 2013, 08:09:51 PM »
Thank you!! That has helped a lot.  The clinic owner pays the doctor for services he renders to the patient and the doctor is credentialed through most of the insurance plans, but the clinic is not, so I just wanted to make sure I was not missing anything.

Thanks again! :)

RichardP

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Re: who should be credentialed
« Reply #4 on: April 18, 2013, 09:01:29 PM »
desheba - I intentionally did not give you the detail that Billergirlnyc gave because your client needs to pay a healthcare attorney in your state to get the details right for your state.  Billingirlnyc said, essentially, sometimes it is this way and sometimes it is that way.  I know that.  I intentially did not say that, and I wish she also had not said that, because you need to get it right for your state.  It does not matter to your client that it may be a certain way in other states.  It matters to your client what it is in your state.  This is the angle I was coming from in my initial response to you above, and in my response below.

I am concerned by your statement I just wanted to make sure I was not missing anything.  You cannot possibly know from Billergirlnyc's answer whether you are missing anything or not.  Only a healthcare attorney who knows the regulations of your state can know that.  You are setting yourself up for trouble if you present yourself to your client as being the final answer on this issue.  You can certainly work it so that you are the final answer for your client.  But you cannot know that your final answer is the correct one until it is vetted by the one who is licensed to be an agent of your state and to know the correct answer to these things (the healthcare attorney).  That is why they exist.

You consistently distinguish between the clinic owner and the doctor who sees the patients, so I am assuming they are two different people.  Therefore, I am also concerned that you are satisfied that the doctor who does the work is credentialed.  If the doctor who does the work is being paid by someone else, the billing cannot be submitted in the name of the doctor who does the work.  Therefore, it does not matter if the doctor who does the work is credentialed (since billing is not being submitted in his name).  The billing must be submitted in the name of the entity who is paying the doctor who does the work.  And it is that entity (owner of clinic, or the legal name of the clinic) that must be credentialed.  If the hiring entity is not credentialed, it will not matter that the doctor who did the work is credentialed - because that doctor cannot bill for his services, since he is being paid by the hiring entity.

You don't say whether the hiring entity is already credentialed, so that is why I am emphasizing that it is the hiring entity that holds our focus here, not the doctor who has been hired.

desheba

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Re: who should be credentialed
« Reply #5 on: April 18, 2013, 09:17:20 PM »
I am sorry if it sounded like I did not understand. Richard, I completely understand the info you are giving me.  I plan to talk to the client in the morning about getting him (the clinic/entity) credentialed and not focus so much on the physician since he is paid by the clinic for his services. I think I got it....now!

RichardP

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Re: who should be credentialed
« Reply #6 on: April 18, 2013, 11:29:17 PM »
desheba - Please check to see if the clinic has its own Taxpayer I.D. and if the clinic owner has his own, separate Taxpayer I.D.  Then answer the question (to yourelf, not to me): who hired the doctor who does the work, and under what authority?  The owner(s) of a clinic, and the clinic itself, can be two separate legal entities.  Or the owner of a clinic can be a legal entity while his clinic is not.  You need to be concerned about credentialing the legal entity (Taxpayer I.D. #)  that hired the doctor and that pays the doctor (the hiring, and paying for work done, and billing should all be done by the same Taxpayer I.D. #).

I am currently involved in several different situations where a number of doctors (who each have their own Taxpayer I.D.s and credentialing, or not) own a legal entity that has its own Taxpayer I.D. and credentialing.  The doctors have their own private practices and can hire and pay other doctors/NPs/etc. and bill for that work under their own Taxpayer I.D. and NPI Number because the work was done under their legal name.  But these doctors are also paid by the legal entity that they own, as are other doctors/NPs/etc. hired by that legal entity that they own.  The work that is done for the legal entity is billed under the Taxpayer I.D. and NPI Number and credentialing of the legal entity.

A number of the doctors who own the legal entity - and who are paid by that legal entity - are non-participating providers for all insurances except Medicare.  Yet the legal entity is able to bill all insurance carriers for the work done for it by those doctors (who own the legal entity) - because the legal entity is credentialed, and it is the legal entity doing the billing for the work done under its legal name.

I've been through this.  So I would feel much better if you had said instead Richard, I completely understand the info you are giving me.  I will immediately tell my client that this situation is beyond my level of expertise and will advise him that he needs to get the opinion of healthcare attorney.  Instead, you said I plan to talk to the client in the morning about getting him (the clinic/entity) credentialed ...  If him and the clinic/entity both have Taxpayer I.D. Numbers (and maybe both have NPI Numbers), how do you know which one should be credentialed?  (Hint: which one hired the doctor and pays him?)

An advisor offers the best value to their client when they know the limits of their knowledge and know when to hand the client off to someone else to get answers to certain questions.  I will repeat myself from the end of my first post above, and then leave this discussion. 

For reasons such as this, you should not be giving any advice to anyone re. the question you just asked.  That is the sort of question only a health-care attorney who knows the requirements of your state and the CMS requirements should be addressing.
« Last Edit: April 18, 2013, 11:39:48 PM by RichardP »

RichardP

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Re: who should be credentialed
« Reply #7 on: April 18, 2013, 11:39:01 PM »
Billergirlnyc - in response to your most recent post above.  I think you and I agree that desheba's client needs to know what is correct for his state, and not for someone else's.  I think you and I agree that the legal structure of a business is the business of a healthcare attorney, not a biller (as has been pointed out so many times in other places on this board).  Both of those issues are what I thought were on Page 1.  I do not think this discussion with desheba has gotten past what I wrote in my first response.  But I think your comments are jumping over the truth in the following quoted paragraphs and dealing with stuff that comes later on.  I am encouraging desheba to be certain of the issues contained in the following quoted paragraphs first.  But I think most on this board would agree that the biller is not the one expected to know the answer to these issues.

In response to desheba's statement The clinic wants to get paid for the services the provider renders ...  I responded with the material quoted below (and it is only that statement that I am taking issue with because how can desheba know whether the clinic qualifies to get paid?):

For this to be legal (that is, for the clinic to get paid), the clinic must be the entity who hires the doctor doing the work, and bills for the work done in its own name.  In order for the clinic to be able to do this, certain state-imposed requirements must be met.  If the client/clinic are also treating Medicare patients, Federal-imposed requirements must be met.

For reasons such as this, you should not be giving any advice to anyone re. the question you just asked (about the clinic getting paid).  That is the sort of question only a health-care attorney who knows the requirements of your state and the CMS requirements should be addressing.

desheba

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Re: who should be credentialed
« Reply #8 on: April 18, 2013, 11:55:05 PM »
Okay...so I am going try to see if I understand....my client owns a clinic which does have its own tax id, but the owner is not a physician he hires a physician to see patients in his clinic. The owner/clinic is not credentialed but the physician is. In order to bill appropriately, the clinic needs to be credentialed after speaking with their health care lawyers (which they have already) to make sure everything is legit. Am I correct?

I appreciate your time in helping me understand!

RichardP

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Re: who should be credentialed
« Reply #9 on: April 19, 2013, 12:37:58 AM »
Short answer - yes.  Thanks for the information.

The doctor emplyoyee may be credentialed but that is irrelevant in this situation.  He is already being paid, so he cannot bill the insurances.  The entity that is authorized to pay the employee and bill the insurances (which appears to be the clinic) is who needs to be credentialed.  And part of that process will be submitting a list of all owners of the clinic.  That much I know to be true.  From the situations I have been involved in, the list submitted did not need to include the employees of the billing entity - just the owners (in this case, the credentialed doctor is only an employee, so in my case he would not need to be on the list).  From what Billergirlnyc said, that may vary from state to state.  You will probably have to ask each carrier you want to be credentialed with about it.


This is what I was trying to flush out.  From your response:

1.  client owns a clinic;
2.  owner is not a physician;
3.  a clinic which does have its own tax id;
4.  owner/clinic is not credentialed;
5.  physician [employee] is [credentialed];
6.  clinic needs to ... [speak] with their health care lawyers (which they have already)

Your initial question made me think this might be the case.  It sounded like the owner of the clinic might not be a doctor.  I know that in some states, it is not legal for a non-physician to own something.  I can't recall what right now, but I think clinic.  That is why I emphasized the point of speaking with a health-care lawyer.  They will know whether the set-up you described is legal in your state, and if it is not, what should be done to make it legal.

Billergirlnyc wondered whether she was on Page 2, and for me, the answer is yes.  She was talking about credentialing the entity that is authorized to bill.  My Page 1 was all about being sure of which entity is authorized to bill first, and then consider credentialing.  I don't think anything she said is incorrect.  I just think she confused the issue by offering the credentialing information before you told us who the billing entity is.

desheba

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Re: who should be credentialed
« Reply #10 on: April 19, 2013, 08:39:13 AM »
Thanks Richard and Billergirlnyc.....this answered my question!  sorry for all the confusion....we are in florida so, I will research further about the state requirements.  I appreciate all of your help! :)

RichardP

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Re: who should be credentialed
« Reply #11 on: April 19, 2013, 10:54:28 AM »
You are welcome.  Thanks for being tenacious.  Please humor me and read through the quoted info below - to see where I was coming from with my questions.  If your setup was in California, it would be illegal.  I'm guessing it is probably also illegal in Florida - but that is for your folks to find out on their own.  I'm just raising the red flag.  And note that this issue must be resolved before we can begin to move toward the issue of credentialing.  Good luck.

For the benefit of any passers-by, here is the California Code prohibiting ownership of medical clinics by non-physicians.  This was the issue that attracted my attention in the initial post, and is why I wanted to know who hired the doctor in question.  This is definately a state issue.  But it is also a Federal issue if Medicare patients are involved.  I can't imagine that any state would deviate too far from what is quoted below - but only the appropriate health-care attorney would know for sure (or someone who actually reads the business code of the particular state ;)).

From here:

http://www.mbc.ca.gov/licensee/corporate_practice.html

The following is to provide guidance to physicians on the prohibition against the corporate practice of medicine.

Note: This area of law can be complicated, therefore physicians are encouraged to discuss their medical practices and business enterprises with appropriately knowledgeable legal experts. The Medical Board of California continues to receive complaints and inquiries about the law, and some repeating issues are presented here.
...

In addition, the following "business" or "management" decisions and activities, resulting in control over the physician's practice of medicine, should be made by a licensed California physician and not by an unlicensed person or entity:

 * Ownership is an indicator of control of a patient's medical records, including determining the contents thereof, and should be retained by a California-licensed physician.
 * Selection, hiring/firing (as it relates to clinical competency or proficiency) of physicians, allied health staff and medical assistants.
 * Setting the parameters under which the physician will enter into contractual relationships with third-party payers.
 * Decisions regarding coding and billing procedures for patient care services.
 * Approving of the selection of medical equipment and medical supplies for the medical practice.

The types of decisions and activities described above cannot be delegated to an unlicensed person, including (for example) management service organizations. While a physician may consult with unlicensed persons in making the "business" or "management" decisions described above, the physician must retain the ultimate responsibility for, or approval of, those decisions.

The following types of medical practice ownership and operating structures also are prohibited:

 * Non-physicians owning or operating a business that offers patient evaluation, diagnosis, care and/or treatment.
 * Physician(s) operating a medical practice as a limited liability company, a limited liability partnership, or a general corporation.
 * Management service organizations arranging for, advertising, or providing medical services rather than only providing administrative staff and services for a physician's medical practice (non-physician exercising controls over a physician's medical practice, even where physicians own and operate the business).
 * A physician acting as "medical director" when the physician does not own the practice. For example, a business offering spa treatments that include medical procedures such as Botox injections, laser hair removal, and medical microdermabrasion, that contracts with or hires a physician as its "medical director."

In the examples above, non-physicians would be engaged in the unlicensed practice of medicine, and the physician may be aiding and abetting the unlicensed practice of medicine.