A Quick Breakdown of Billing and Credentialing New Grads and Doctors

A Quick Breakdown of Billing and Credentialing New Grads and Doctors

A Q&A with WeCredential Manager Dave Kegel

From billing locum tenens to CAQH applications to when you can start billing under a new grad: there are plenty of misunderstandings about billing and credentialing. Dave Kegel, Manager of WeCredential, breaks down your most pressing questions to help you with billing and credentialing new providers.

Q: I’m opening a cold start with only me as a doctor. Do I need a group NPI?

DK: It depends on how your organization is classified. Usually, if it's classified as an individual or sole proprietor, most payers will not allow you to have a group contract. That’s in comparison with an S Corp or an LLC. So, check your classification. If you are classified as anything other than a sole proprietor you will likely need a group NPI for at least some payers.

Q: My new grad is seeing patients prior to credentialing. Can I bill under the owner while waiting for the new grad to be credentialed if the owner reviews the charts?

No, you're not supposed to do that. In an optometry school setting, payers allow that. But once a new grad is hired by a practice, you should not bill under a different provider.

Q: We are hiring a doctor from a different practice. Could you review the basic steps to get her credentialed?

First, the new provider must add their new practice location to their CAQH. It’s important to keep their CAQH up to date.

If the provider is already credentialed with the insurance payer in that state, then only a demographic update needs to be done. Either adding that provider to the existing group contract or adding the new practice to the provider’s individual contract. Whichever applies. If the provider is not currently credentialed with the payer, then a full application will need to be submitted, credentialing the provider and adding them to the group (if applicable).

On the flip side, if you have a doctor that's leaving, you want to make sure to reach out to each payer and term that doctor. Otherwise, they're going to continue to show up in the provider directory, and you'll get patients asking about that doctor who’s no longer there.

Q: When it comes to locum tenens, how long can you bill before they are considered a new provider by payers?

Most of the payers follow Medicare's rules on that. You can bill locum tenens for 60 days. For example, if you have a provider that's out on maternity leave and you have somebody filling in, then you can bill under locum tenens for 60 days in that scenario. But it does not cover new grads, or other non-credentialed providers that are part of your practice.


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