pshypyre Posted February 25, 2016 Share Posted February 25, 2016 I have a couple of questions: 1) What is credentialing for? 2) Does a PA have to be credentialed if claims are being submitted under the name of supervisory physician? 3) How does one get credentialed with BCBS in the state of Virginia??? Is it a simple process or complex one??? Quote Link to comment Share on other sites More sharing options...
Reality Check 2 Posted February 25, 2016 Share Posted February 25, 2016 You will need to talk to someone in your employer organization for clarification on your state. Credentialing is necessary for you to see patients who have any insurance - you are credentialed by EVERYONE from state insurance, workers compensation, private insurance, hospitals, etc. They verify who you are, verify your accredited education and licensure, verify your NCCPA and make sure you are not a criminal or have extensive malpractice history or litigation. It takes FOREVER. I have been credentialed with one insurance through one employer and had to redo it with a change of employer and have it take 3 months despite a long history of having been paid by them before. It makes no sense but it is like the IRS - it has to happen. Find someone at your employer who handles this and ask questions and participate in the process. If you fill out one TINY box or leave it blank on an intake form - your application goes back or goes to the bottom of the pile. This is a career long process. If someone at your employer is really good at it - it will be painless for you. If it is a solo practice or the department is not strong - you will have to learn to do the majority of the legwork on your own. Quote Link to comment Share on other sites More sharing options...
jmj11 Posted February 27, 2016 Share Posted February 27, 2016 The honest truth is that credentialling is one of hundreds of strategies that insurance companies have created to avoid paying practices. There is no place for it as the states, and the states only, have the authority of declaring a provider fit to provide medical services. Insurances use this process to delay payment of new providers (sorry, we can't pay for those visits because the provider wasn't credentialed with us yet.") Then the credentialing has to be kept up to date or once again the insurance companies will deny payment ifyou don't update your information on a regular basis. So now, rather than getting one license in your state to practice, to get paid, you have to get 15-20 separate "licenses." That is my opinion. 2 Quote Link to comment Share on other sites More sharing options...
cboylb Posted June 2, 2016 Share Posted June 2, 2016 I was under the impression that a pa didn't necessarily have to be credentialed with insurances as long as the SP was. And when the claim is submitted, you use the SP'S credentialing,but the pa's NPI, and the insurance would automatically reduce reimbursement to the pa rate. Is this true? I work in TN, and one of my employers never bothered to credential any mid-levels for this reason. Quote Link to comment Share on other sites More sharing options...
Maverick87 Posted June 2, 2016 Share Posted June 2, 2016 I was under the impression that a pa didn't necessarily have to be credentialed with insurances as long as the SP was. And when the claim is submitted, you use the SP'S credentialing,but the pa's NPI, and the insurance would automatically reduce reimbursement to the pa rate. Is this true? I work in TN, and one of my employers never bothered to credential any mid-levels for this reason. Nope. You need to be credentialed with the insurance companies. If you are billing under the doctor's credentials, they are being reimbursed based on those credentials (you can't bill under an NPI). This is fraud and you can get in trouble for that. Quote Link to comment Share on other sites More sharing options...
coloradopa Posted June 3, 2016 Share Posted June 3, 2016 Nope. You need to be credentialed with the insurance companies. If you are billing under the doctor's credentials, they are being reimbursed based on those credentials (you can't bill under an NPI). This is fraud and you can get in trouble for that. Most of this is available on the AAPA website if you are a member. But for those who aren't: Almost all private insurance companies cover medical and surgical services provided by PAs. However, with scores of different payers and plans, including preferred provider organizations (PPOs) and health maintenance organizations (HMOs) providing coverage in the United States, there may be differences both in how services delivered by PAs are covered and how claim forms should be filled out. Even within the same insurance company, PA coverage policies can change based on the particular plan type or the specific type of service being provided. Although many private payers do not separately credential PAs or issue provider numbers, PAs are generally covered for most services they provide. Each practice must ascertain payment policy and claims submission instruction from each payer with whom they contract. When plans do not credential or issue provider numbers to PAs, they typically instruct the practice to bill the service under the name of the supervising physician, occasionally with a modifier code attached. It is critically important that one not assume a policy for billing for PAs. Obtain specific information from a reliable source within the insurer, preferably in writing. Consider starting with your payer’s provider representative. 1 Quote Link to comment Share on other sites More sharing options...
Maverick87 Posted June 3, 2016 Share Posted June 3, 2016 Most of this is available on the AAPA website if you are a member. But for those who aren't: Almost all private insurance companies cover medical and surgical services provided by PAs. However, with scores of different payers and plans, including preferred provider organizations (PPOs) and health maintenance organizations (HMOs) providing coverage in the United States, there may be differences both in how services delivered by PAs are covered and how claim forms should be filled out. Even within the same insurance company, PA coverage policies can change based on the particular plan type or the specific type of service being provided. Although many private payers do not separately credential PAs or issue provider numbers, PAs are generally covered for most services they provide. Each practice must ascertain payment policy and claims submission instruction from each payer with whom they contract. When plans do not credential or issue provider numbers to PAs, they typically instruct the practice to bill the service under the name of the supervising physician, occasionally with a modifier code attached. It is critically important that one not assume a policy for billing for PAs. Obtain specific information from a reliable source within the insurer, preferably in writing. Consider starting with your payer’s provider representative. Good info. Didn't know that. Here's the link: https://www.aapa.org/WorkArea/DownloadAsset.aspx?id=1256 Quote Link to comment Share on other sites More sharing options...
UGoLong Posted June 6, 2016 Share Posted June 6, 2016 Docs, PAs, and others are credentialed. It is actually an ongoing process in that, using CAQH online about 3 times per year, you keep the world up to date as to the currency of your licenses, ACLS, and other documents. CAQH also has a description of the practice that you work in. You also attest to not having used drugs, been arrested, etc since the last time they asked. In some cases, you provide new source documents (like new cards). As a practical matter, your practice administrator can do at least some of the work to do this. Before CAQH, each hospital and insurance company would come at you a couple of times a year to see if you renewed one of your cards, got the CME, took your PANRE, got your CME, etc. Rather than think of this as some Machiavellian way to keep you under their thumb, think of it as a way to at least partially insure that providers have current credentials. Without making that effort, the hospital or insurance company might leave themselves open for a lawsuit by putting their patients in the care of someone with out-of-date credentials. As PAs get more autonomy (hopefully), you will see more -- not less -- of this. Quote Link to comment Share on other sites More sharing options...
jmj11 Posted January 8, 2018 Share Posted January 8, 2018 Having worked with and fought with insurance companies for a number of years, when I owned my own practice, I will state a more cynical view of this process. Insurance companies are masters at denying payments for services. I do believe that this whole credentially process is one or their strategies for denying payments. It is ridiculous that in this day and age, that if a hospital or practice hires a new provider, it takes the insurance companies three months to "credential" them. If they see patients before (and often they do, sometimes my mistake) payment for those visits are denied. This process saves the insurance companies hundreds of millions of dollars per year. It is the state's responsibility to make sure a medical provider is qualified to provide medical services. There should be a class action lawsuit to take this government responsibility out of the hands of the insurance industry. I have never heard of or seen a lawsuit against an insurance company for contracting with a provider who had some disqualifying issue. Quote Link to comment Share on other sites More sharing options...
DelawarePA Posted March 9, 2020 Share Posted March 9, 2020 Hoping someone can offer some guidance here. Thought I would just try to continue this thread. I'm a new PA. I'm working for a private practice and I am the first PA that has been employed here. Because it is a small practice I am doing all my credentialing. It's a pain but for the most part I think it's going somewhat smoothly. However, I came across BCBS CareFirst today and they informed me that they do not contract PAs. As someone who is very new to this, I was hoping someone might help me understand how to go about making sure that I am reimbursed appropriately. Or at least nudge me in the right direction. My SP is pretty unfamiliar with the process in regards to PAs so I figured I'd try here. Thanks in advance Quote Link to comment Share on other sites More sharing options...
Violette Posted May 31, 2021 Share Posted May 31, 2021 If you have any problems with Credentialing, I recommend you this company - https://wchsb.com They helped me a lot to solve my re-credentialing problems. Quote Link to comment Share on other sites More sharing options...
tailormade Posted December 7, 2023 Share Posted December 7, 2023 On 3/9/2020 at 11:43 AM, DelawarePA said: Hoping someone can offer some guidance here. Thought I would just try to continue this thread. I'm a new PA. I'm working for a private practice and I am the first PA that has been employed here. Because it is a small practice I am doing all my credentialing. It's a pain but for the most part I think it's going somewhat smoothly. However, I came across BCBS CareFirst today and they informed me that they do not contract PAs. As someone who is very new to this, I was hoping someone might help me understand how to go about making sure that I am reimbursed appropriately. Or at least nudge me in the right direction. My SP is pretty unfamiliar with the process in regards to PAs so I figured I'd try here. Thanks in advance New grad here. To piggyback off this, I was wondering if it is possible to work without being credentialed through insurance. I was offered a part-time job that could start the same week. When I asked if there was any credentialing I had to do through insurance, they said since the SP would be signing off on the notes there was no need for credentialing. Something about this seemed off to me and I ended up not taking the position, but I would like to know for future reference. Being able to start the next day just seemed off to me... Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted January 7 Administrator Share Posted January 7 On 12/6/2023 at 6:44 PM, tailormade said: New grad here. To piggyback off this, I was wondering if it is possible to work without being credentialed through insurance. I was offered a part-time job that could start the same week. When I asked if there was any credentialing I had to do through insurance, they said since the SP would be signing off on the notes there was no need for credentialing. Something about this seemed off to me and I ended up not taking the position, but I would like to know for future reference. Being able to start the next day just seemed off to me... Worked like this for years, unaware of it at the time. Everything I (and presumably all of the PAs or NPs) did was billed as if the SP did it. Very sketchy. He eventually closed that practice and moved out of state, rumors had it the insurance companies caught on; don't know if that was commercial or Medicare that did him in. Quote Link to comment Share on other sites More sharing options...
SedRate Posted January 8 Share Posted January 8 On 12/6/2023 at 8:44 PM, tailormade said: wondering if it is possible to work without being credentialed through insurance Yes, the service can be billed to the patient. On 12/6/2023 at 8:44 PM, tailormade said: the SP would be signing off on the notes there was no need for credentialing Unless the SP saw the patient and provided the service, this is billing fraud. Quote Link to comment Share on other sites More sharing options...
Moderator ventana Posted January 26 Moderator Share Posted January 26 On 1/8/2024 at 8:13 AM, SedRate said: Unless the SP saw the patient and provided the service, this is billing fraud. I was in a practice which did this in the early 2000's actually got audited by medicare and did fine Most insurance companies that if a PA or NP sees the patient and the doc is in the office suit and immediately available it may be billed under the physicians pin. It is not illegal and is one of the dirty little secrets of why the Doc's dont want us to be independent. Think about it - they can hire a PA at < 50% of a doc and yet make the same revenue.... Quote Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted January 26 Administrator Share Posted January 26 2 hours ago, ventana said: I was in a practice which did this in the early 2000's actually got audited by medicare and did fine Most insurance companies that if a PA or NP sees the patient and the doc is in the office suit and immediately available it may be billed under the physicians pin. It is not illegal and is one of the dirty little secrets of why the Doc's dont want us to be independent. Think about it - they can hire a PA at < 50% of a doc and yet make the same revenue.... Same here, 2017-2020, though. Interestingly enough, I looked up the times medicare was billed under my NPI for this practice? Not once during the time I worked there, even though I mostly worked when the doc wasn't on site, e.g. evening walk-in. I suspect that's why the practice closed and the doc left town, but can't prove anything. Quote Link to comment Share on other sites More sharing options...
SedRate Posted January 26 Share Posted January 26 11 hours ago, ventana said: I was in a practice which did this in the early 2000's actually got audited by medicare and did fine Most insurance companies that if a PA or NP sees the patient and the doc is in the office suit and immediately available it may be billed under the physicians pin. It is not illegal and is one of the dirty little secrets of why the Doc's dont want us to be independent. Think about it - they can hire a PA at < 50% of a doc and yet make the same revenue.... Wow! I stand corrected. Thanks for sharing. Do you know if after 20 years that has changed? Quote Link to comment Share on other sites More sharing options...
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