ED Coding & Reimbursement Alert - 2013 Issue 13
PECOS: Get The Skinny On Enrollment Specifications To Avoid Giving Away Services
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Article Overview
This article explains Medicare and payer credentialing timing considerations for new physicians and how enrollment delays can affect billing readiness. It is aimed at practices, billing staff, and compliance-oriented readers who need a general understanding of electronic enrollment, retroactive billing limits, temporary coverage concepts, and the risk of billing under the wrong provider identity. The discussion also references CMS guidance and practical steps practices can take to plan ahead for provider onboarding.
Why This Topic Matters
Provider enrollment timing can directly affect whether services can be billed and paid, especially when a new clinician starts before credentialing is complete. The article helps practices understand the broad compliance and operational issues involved in Medicare enrollment and related payer processes.
Article Sections
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CMS enrollment and overpayment-related denial guidance
Introduces a CMS update affecting enrollment applications and explains why ownership and overpayment status are relevant to practices. Sets the context for the credentialing and billing questions discussed later.
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Can We Bill Retroactively?
Discusses general timing considerations for billing services when a new physician is not yet credentialed. Covers Medicare versus private payer differences and the impact of electronic versus paper application filing.
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Can We Just Use Another Provider’s NPI?
Addresses concerns about billing under another provider identity while waiting for credentialing. Includes a discussion of temporary coverage concepts, locum tenens, and related claim-form information.
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What is the Best Way to Ensure We Get Paid?
Focuses on planning credentialing early enough to support a provider’s start date and avoid payment delays. Includes general operational suggestions for practices onboarding a new physician.
What You Will Learn
- How Medicare enrollment timing can affect when services may be billed
- How payer credentialing processes can differ between Medicare and private plans
- Why billing under another clinician’s identity can create compliance risk
- How locum tenens concepts fit into temporary physician coverage situations
- How practices can plan provider onboarding to reduce payment disruption
Who Should Read This
- Medical practice managers
- Billing staff
- Credentialing staff
- Compliance officers
- Physicians and non-physician practitioners
- Revenue cycle professionals
Modifiers Discussed
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