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Physician Credentialing: Worth Getting Right to Get Paid


While it is cumbersome, re-credentialing physicians with CMS is necessary to ensure payments continue at your medical practice.

Now that CMS has notified us that everyone needs to re-credential with them soon, it seems as if many insurance companies are getting on that bandwagon, too. There will be a flurry of activity for each office once they receive their letter from CMS telling them to re-credential. This is going to make some offices crazy trying to do it correctly and some offices are just going to ignore the letter - don’t. You only have 60 days to respond when you get the letter.

Many offices did their credentialing when the doctor first started out. If the doctor has not done anything significant - according to the doctors - then no one has changed any information with CMS. Many doctors signed up for the National Provider Identifier (NPI) with different information than was in their CMS file. Most doctors got electronic funds transfer (EFT) with Medicare and figured that any other changes were moot; they were getting their money.

That is hugely problematic. Why? Many doctors have moved offices and have changed some information. When letters from CMS go out to old addresses, they are not going to be forwarded. Therefore, doctors are not going to get their notice to re-credential with Medicare. This boils down to all money from Medicare will stop. No doctor, other than pediatricians can afford that!

Now the second problem is that Medicare does not want you to re-credential until you have received the letter. They feel that they will be inundated with applications and not be able to process them within the 90 days required by law.

A third, and much more insidious, problem is that doctors are signed up differently with CMS than they are with NPI. The reason is probably that two different people filled out the forms. I have seen many examples of a doctor being signed up as “John Smith MD” through CMS and when they were signed up with the NPI there name is “John Smith, MD.” That pesky comma is going to cause payments to stop. Any punctuation differences will cause payments to stop. The computers and people at the different Medicare carriers can not accept differences. Often they will have you provide a letter or Form 941 from the Internal Revenue Service to prove the correct name.

I believe that you can be proactive with this problem. I suggest that you go on the NPI website and find out how exactly you are listed and either keep that in mind or list yourself as you really want to be listed. Then, if there have been any changes - such as address, phone number, board certification, etc. - go online with PECOS and submit a corrected enrollment application that matches the NPI information to Medicare. This will do two things: first, update your information that should have been updated before; and second, make sure that your money does not get stopped.

If, however, you have not had any changes, Medicare really wants you to wait until you receive your letter.

Now, with Medicare enforcing the rules that all your information match, you can rest assured that other carriers will also. The best way to be proactive with this is to go on to the Council for Affordable Quality Healthcare (CAQH) website and sign up. In order to get a login ID, you will need to contact one of the insurance carriers you are now with and have them set you up on CAQH. Then go online and take the two or so hours to fully complete entering all information. When most other carriers need to refresh your information they will first go directly to that website and not bother you. Those that don’t use that website (many Medicaids, etc.) are fewer in number than those that do. Therefore, you will have much fewer paper forms to fill out with the exact same information.

If you think that this sounds like a lot of work that you as a provider need not be involved with, you are right and you are wrong. It is a necessary evil that needs to be overseen by you - only if you like being paid for your services. You will notice that many large practices have a person(s) dedicated to doing the credentialing. The same process must be gone through each time a physician joins or leaves a practice, etc. You are correct that it is a lot of work.

Many billing companies and some companies that specialize in credentialing are out there to help you. As they do this on a regular basis they will usually do a good job and take away the nightmare of paperwork for you. However, you need to be ready to sign any form they bring over to you. When you sign it, please give it at least a cursory look to make sure the information is correct. Remember, when you sign the applications you are attesting that the information is correct. Just like on a claim form, when you sign it (whether with a pen or electronically) you are the one who is legally responsible for the information.

Remember, credentialing is a royal pain in the neck; but it must be done and done correctly. Do not delegate it to the lowest paid office worker you have. As you do not want any hiccups in your cash flow, delegate it to whomever has the same priorities as you - getting cash flow for your office.

Find out more about Sue Irwin and our other Practice Notes bloggers.

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