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Billing for lcsw

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RichardP:
Linda, I don't know mental health, so I cannot provide any detailed answers in that area.  Healthy sounds like s/he is new to all of this so I gave a general framework that s/he can respond to.  Based on that response, we can further refine our responses.  Don't want to overwhelm Healthy with all of the permutations that are possible.

It isn't clear to me whether Healthy's "Group" meets the CMS definition of Group.  If it doesn't, the requirements are different from what they are for a CMS-defined Group.  Further, it is not clear whether Healthy's lcsw is intended to be a member of the Group, or simply an employee or subcontractor of the Group, regardless of whether it is CMS-defined.  From the link I provided in my initial response, you can see that a CMS-defined Group can have employees and subcontractors.  These employees and subcontractors would not be members of the Group, and so credentialing requirements would be different than for members of the Group.

For a collection of workers to meet the CMS definition of "Group", the pay of Group members must be set by formula.  Payment cannot in any way be directly tied to productivity.  Since Healthy's lcsw is being paid per patient, that is a direct link between productivity and pay.  Therefore, the lcsw cannot legally be a member of the Group.  S/he must be either an employee or subcontractor.

Your statement about credentialing requirements are correct for members of a CMS-defined group, where the legal entity of the Group name is who gets paid from the carriers.  (And as you said, the carriers must have a list of all members who belong to the Group; new members must be added to that list before the carrier will pay the Group for the new member's work.)  But, so far as I understand it, those credentialing requirements do not extend to employees or subcontractors of the Group.  As I stated above - if a Nurse Practitioner is authorized to bill in their own name, they can - but they will be paid less than if they bill in the name of their employer.  Two situations:  if they bill in their own name, the Type 2 (who gets paid) and Type 1 (who did the work) NPI numbers must belong to the Nurse Practitioner.  Payment goes directly to the NP, but at a reduced rate; if they bill in the name of their employer, the Type 2 (who gets paid) NPI number must be that of their employer, and the Type 1 (who did the work) NPI number must be their own.  I know this setup applies to Nurse Practitioners.  I do not know if it also applies to Healthy's lcsw.

Healthy needs to come back with some more-specific information before we can begin to know how to tailor our responses.  If Healthy is new to this, s/he may not know what that specific information is.  That is why I began the narrowing-down process by asking who pays the lcsw.  That will hint at whether the lcsw is a member of the Group, or an employee or subcontractor.  Since the lcsw is being paid per patient, I'm guessing s/he is an employee or subcontractor.  If s/he is a member of the Group, then the Group is violating the requirements that must be met in order to be considered a CMS-defined Group.

Healthy:
Ok. Yes I am very new to this field , here is my case.
Doctor was solo practioner and has a group NPI and has proffesional corporation(PC).
Recently he start hiring APRN and LCSW and LPC's. all of them work part time for fee for service, they get paid by Doctor according to agreement they made. When they see patient they get paid for that.
No other benefits are provided to them as they work few evenings.
I am not sure about credentialing process, how it is set up at carrier level.
All I know is that they are credential with some carriers and rest like Cigna and UHC has closed their network for LPC's and LCSW's in my area.
I am billing for their services under group NPI and use their NPI as rendering provider, no modifier is used and no supervising physician's NPI is used.
Now my concern is that how I can bill their services to the carrier who have closed their network for them?
I hope this will clear my case and I will get right advice.
If still its not clear , please let me know.
Thanks

Healthy:
Please answer me.

PMRNC:

--- Quote ---Your statement about credentialing requirements are correct for members of a CMS-defined group, where the legal entity of the Group name is who gets paid from the carriers.  (And as you said, the carriers must have a list of all members who belong to the Group; new members must be added to that list before the carrier will pay the Group for the new member's work.)  But, so far as I understand it, those credentialing requirements do not extend to employees or subcontractors of the Group.  As I stated above - if a Nurse Practitioner is authorized to bill in their own name, they can - but they will be paid less than if they bill in the name of their employer.  Two situations:  if they bill in their own name, the Type 2 (who gets paid) and Type 1 (who did the work) NPI numbers must belong to the Nurse Practitioner.  Payment goes directly to the NP, but at a reduced rate; if they bill in the name of their employer, the Type 2 (who gets paid) NPI number must be that of their employer, and the Type 1 (who did the work) NPI number must be their own.  I know this setup applies to Nurse Practitioners.  I do not know if it also applies to Healthy's lcsw.
--- End quote ---

Although I agree that CMS guidelines are similar with other carriers, it is MOOT with mental health because of the TPA's used. Her original post mentioned two commercial carriers that both use TPA's.. up to 4 or 5 of them with the carriers she mentioned depending on the PLAN.  The CMS guidelines of a GROUP isn't the only condition and because she was clear this was a mental health provider I don't think it accurate to just give her the CMS guidelines and also my final statement was that this was a legal entity situation that an attorney for the provider should be resolving, it's not up to a medical billing to define a legal entity.



--- Quote ---Doctor was solo practioner and has a group NPI and has proffesional corporation(PC).
Recently he start hiring APRN and LCSW and LPC's. all of them work part time for fee for service, they get paid by Doctor according to agreement they made. When they see patient they get paid for that.
No other benefits are provided to them as they work few evenings.
I am not sure about credentialing process, how it is set up at carrier level.
All I know is that they are credential with some carriers and rest like Cigna and UHC has closed their network for LPC's and LCSW's in my area.
I am billing for their services under group NPI and use their NPI as rendering provider, no modifier is used and no supervising physician's NPI is used.
Now my concern is that how I can bill their services to the carrier who have closed their network for them?
I hope this will clear my case and I will get right advice.
If still its not clear , please let me know.
--- End quote ---

I'm not FULLY comfortable giving a legal definition as I can only go by what I know and while Richard gave you CMS guidelines they are indeed differen where mental health is concerned in credentialing with group health plans. IF this will be a true "GROUP" and the GROUP is credentialed with a carrier that is claiming they are now closed, they SHOULD be able to ADD the provider according to the scope of their license and state you are in to the GROUP contract. But again, remember that if they are in network with Aetna they may NOT be in network with the TPA's that handle the mental health claims for managed care plans. So while credentialing with Aetna is fine, there may be Aetna plans that use TPA's you may not be in network with. From my own knowledge in the states I work in I can name at least 3 major TPA's that Aetna uses, and again it depends on the plan. The same goes for BCBS, they too use TPA's, their biggest being Magellan Behavioral.   Now I know that was not your question but I did want to make sure you had a clear understanding in credentialing with carriers that have TPA's to process mental health plan. Those TPA's have their own method of credentialing. IF your provider has a contract with the carrier OR TPA, then you can indeed add a provider according to their scope of license/credentials to an existing contract, EVEN if the network is closed because the group is already contracted, you merely just need to add the provider to the credentialing process. What I do is make it really simple for myself and CALL the carrier/TPA of that plan and ask THEM how they want you to do it. I've seen small TPA's merely only need a name, license number and copy of current license and they will retroactively put them on the contract as of the day they started with the group (FOR existing network contracted providers)  IF The group is NOT credentialed with a closed panel, all is not automatically lost. I dig a bit deeper to find out how and IF it's possible I can get my client onto a closed panel, that does indeed get a bit more involved but it's not impossible all of the time. The carrier will usually give you criteria to appeal a closed network as they have criteria they use to go around the closed panel. For example I had a provider that provided biofeedback and was able to credential with a carrier that was a closed network because he was the only one within 100 miles providing Biofeedback (JUST an example).  I also took note that your group had a physician in it and you stated that the carriers you mentioned were closed to LCSW's, but again that is normally for NEW provider's and your group is already credentialed. Also you only mentioned the commercial carriers and again, not the TPA's which do require separate credentialing.   Now it is quite possible since your provider was a psychiatrist that he only credentialed with the major medical carriers and NOT the TPA's because of his credentials as a physician they didn't question it and it wasn't needed. 

Bottom line, best place to get the answer you need is to contact each carrier that your client HAS A CONTRACT with and ask them this exactly "How do we add a provider to our network contract"?  They will give you the procedure.    Your other question PRIOR to this was more about what a group was, how it's defined, etc and I'm again stating this isn't a part of the scope of our services and should not be something we consult with or about.  JMHO.


--- Quote ---Please answer me.
--- End quote ---

This is a public forum, it's not like we receive emails with an urgent requirement to respond. Some of us frequent daily and others weekly or whenever we can find the free time as a courtesy.

RichardP:
Linda, thanks for the comments.

... while Richard gave you CMS guidelines they are indeed different where mental health is concerned in credentialing with group health plans.

And now I've learned something.  As I stated, I don't know mental health billing.  Which is why I started off by saying these are my assumptions, and my response is based on these assumptions.  If my assumptions are not correct, then my answer should be suspect - since I do not know mental health billing.

... it's not up to a medical billing to define a legal entity.

This really wasn't about defining a legal entity.  It was about asking who was paying the lcsw.   Then I gave some background information for why that would matter in the case of a Nurse Practitioner - since Healthy said s/he was new to the process.  Again, if my assumptions were not correct, my response would be suspect.  But I hoped my response would draw more useful details out of Healthy.

So - I have a question about mental health billing, if Linda or anyone else can answer it:

For regular medical care, a Nurse Practitioner can bill in their own name, for less pay, and if they are properly credentialed.  Or they can bill in the name of their employer, for 100% of what the employer is entitled to.  If they are being paid for their work by their employer (whether solo practitioner or medical group), they NP cannot put their Type 2 NPI number (who gets paid) on the billing form.  They must use the Type 2 NPI number of whoever is paying them.  If the employer is paying the NP, it only matters if the employer is a participating provider.  When using the Type 2 NPI number of the employer, payment of charges will be at the participating provider rate if employer is a participating provider - regardless of whether the NP is credentialed as participating.

Does any one know if this is also true for an lcsw?

... it's not up to a medical billing to define a legal entity.

But, if medical billers need to become consultants in order to survive going into the future, then knowing something about what I've stated in this thread, and what is stated in the link I provided in my first post above will be useful in the role of consultant.

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