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who should be credentialed

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desheba:
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:
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.

RichardP:
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:
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:
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.

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