Billing non-credentialed providers is a common challenge for healthcare administrators and practice managers. When a new provider has not yet completed the crucial credentialing process, submitting claims while staying compliant requires a clear, proactive strategy. Failing to follow payer rules can lead to immediate claim denials, serious compliance violations, and significant lost revenue.
1. Billing Under a Supervising Provider
One highly effective, compliant method is to bill services under a credentialed supervising provider. This is allowed by many payers—but only if the services adhere strictly to specific rules:
- The services must be within the supervising provider’s scope of practice.
- The encounter must be properly documented to show the required level of supervision.
- The billing must comply with the payer’s rules for “incident-to” billing or direct supervision.
2. Review Payer Rules Before Billing
Not every payer allows billing for services performed by non-credentialed staff, even under supervision. It’s absolutely critical to confirm each payer’s specific policies. For instance, you must know if temporary billing is permitted, and always keep written confirmation of those policies for audit preparedness.
3. Use the Right Modifiers
When billing non-credentialed services, accurate modifier use is essential for payer adjudication:
- Modifier Q6 – Used for locum tenens (temporary substitutes).
- Modifier SA – For non-physician practitioners working under supervision.
Correct modifiers help payers understand the unique billing arrangement and significantly reduce denials.
4. Start Credentialing Early
Delays in the credentialing process are the primary bottleneck for revenue flow. Begin applications as early as possible—ideally $90+$ days before a provider starts seeing patients. This drastically minimizes the window of non-credentialed service.
5. Track Claims and Maintain Strong Documentation
Always document who actually performed the service, the supervising provider’s role, and how the service was ultimately billed. Closely monitor all claims for errors or rejections, and respond promptly to avoid missing appeal deadlines.
Conclusion
Navigating billing non-credentialed providers successfully requires thorough documentation, timely credentialing, and strict adherence to payer policies. In summary, proactive planning is essential to maintain cash flow, stay compliant, and minimize audit risk.