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who should be credentialed

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desheba:
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:
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:
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.

desheba:
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:
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.

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