Questions on Credentialing????

[pshypyre 12]

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???

[Reality Check 2 1,821]

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.

[jmj11 974]

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.

[cboylb 10]

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.

[Maverick87 264]

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.

[coloradopa 104]

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. 

[Maverick87 264]

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

[UGoLong 2,546]

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.

[jmj11 974]

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.

[DelawarePA 1]

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