A Q&A with credentialing expert Linda Georgian

The Medicare and Medicaid credentialing process can be difficult to manage, with many steps and nuances to consider. Luckily, ophthalmic practices have an expert to lean on.

Linda Georgian, COE, has more than 40 years of experience within the ophthalmic industry, most recently as a health-care consultant. I sat down with her to ask some of the top credentialing questions we receive from clients. Please note the following has been minimally edited for clarity.

Q. What are your thoughts on outsourcing credentialing vs a practice performing it in-house?

A. I am not opposed to outsourcing it if you can find a great company to manage it. However, it is very hard to find that great company.

Q. What about staffing for credentialing within a practice? Do you have any best practice benchmarks for staffing? Is there a specific ratio of providers to credentialing staff that you find works?

A. Depending on practice size, credentialing may not be a full-time job, but it is very time consuming and requires a very organized individual to keep track of deadlines. The credentialing responsibilities include keeping track of doctor and practice details, disseminating information, keeping detailed and organized records, updating those records (including licenses and malpractice certificates), and reading through a lot of payer mail each day.

My advice: If your practice is growing — especially if you are looking to expand or bring on new providers — keep a “Master Insurance Grid” in Excel containing information on each provider; add new providers as they come on board. Ensure you have a process for the mail that comes in pertaining to each payer’s coverage, paying close attention to rates changing and new precertification requirements, and update the Master Insurance Grid accordingly.

Although there isn’t a published staffing benchmark for credentialing, I would recommend that for every 15-20 providers there is a full-time credentialing staff member. For smaller practices, administrative staff can share the burden.

Q. We have seen some hefty fines issued for billing under the wrong provider of services. When may a provider bill under another provider due to credentialing issues?

A. There is a very limited circumstance where this would be allowed. A locum tenens (or fee-for-time compensation with Medicare) situation where a provider is leaving or going on leave and a new or temporary provider is taking his or her place is the most common situation. Even that is rare.

If a new provider is joining a practice, that provider cannot bill under the senior provider while waiting to be credentialed. Medicare would consider this a false claim.

Q. While there are subspecialty ophthalmic secondary taxonomy codes that we know will have future utility in analytics for payers, where do secondary taxonomy codes play into credentialing for subspecialty providers today?

A. I have not seen secondary taxonomy codes being used in credentialing yet. While there is usually a place for them on credentialing forms, they are not chosen in the final application process. Currently, I do not see a value in using these subspecialties.

Q. There has been a lot of talk about errors in revalidation activities for practices, and practices have been caught by surprise. How often does the revalidation process occur?

A. The revalidation cycle is every 5 years for physicians and ASCs, and optical (DMEPOS [durable medical equipment, prosthetics, orthotics and supplies] suppliers) revalidate every 3 years.

Q. Where can practices check to confirm/determine the deadline for revalidation?

A. You can look up your revalidation date on the CMS website (https://data.cms.gov/tools/medicare-revalidation-list ), but I’ve found the CMS list isn’t always accurate. It is best to check your providers’ statuses through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) website. Once you log in, if an NPI (National Provider Identifier) is up for revalidation, there is a flag in the “Existing Enrollments” box indicating revalidation is coming up.

Once you know your revalidation dates, I would suggest marking your calendar for the next revalidation, so it doesn’t fall off your radar.

Q. I know you have some horror stories about deactivations with Medicare either through revalidation misses or mistakes in original credentialing. How might someone be deactivated? If deactivation occurs, how does one reactivate?

A. When a revalidation date is missed, that puts the person into a deactivation status. Sometimes the only way a practice finds out is because reimbursement has stopped. Unfortunately, if deactivation occurs, the credentialing process starts anew. It is not possible to get a retroactive reactivation from the date when the person was deactivated.

Also, if you haven’t filed a claim in a 12-month period, Medicare can deactivate a provider. Typically, this is because the NPI number isn’t being used. I have seen many errors where billing is performed using the wrong NPI and a doctor or even a second ASC location is deactivated. This usually occurs when adding a new provider or ASC or DMERC (durable medical equipment regional carrier) location. Please be sure you are set up properly regarding NPIs in your practice management system for billing.

I always suggest when updating an enrollment record that practices use the electronic Medicare enrollment version through PECOS, which helps to speed up the reactivation and enrollment processes.

Q. More practices are employing differing provider types — all eligible for Medicare enrollment. Are there any credentialing differences between physicians (MDs, DOs, ODs) and other providers such as physician assistants (PAs) and nurse practitioners (NPs)?

A. MD, DO and OD applications are the same with Medicare. PAs and NPs may have a few additional questions, but otherwise the process is the same.

Q. With so many practices being acquired, merging and consolidating, we have received multiple questions on optical credentialing around appropriate NPIs and tax identification numbers (TINs). What are your thoughts on the most critical optical credentialing factors during and following these transactions?

A. The optical TIN can be the same as the practice, but the NPI is where people get hung up in credentialing. Optical has its own taxonomy code separate from the provider group, so it needs to have its own NPI. Each optical location also needs its own NPI. Ensure that you are setting this up correctly during and after practice transactions, so you don’t find errors that can hold up revenue when growing and adding locations.

Q. We have received questions about some providers within a practice taking insurance and others not. What are some credentialing nuances in this situation? Are there any group NPI issues in this scenario?

A. If you have a provider who does not take insurance and you bring in a new provider who plans to take insurance, including Medicare, it makes sense to separate them business-wise with different TINs. I often see this with LASIK or plastics practices that do not take insurance but then they hire, acquire or merge with a provider who does take insurance. Under Medicare, if you are in the same group, all providers need to be credentialed.

Q. Do you have any specific credentialing horror stories you can share with us?

A. One I have seen is a lot of providers thinking they were revalidated, and they weren’t. It used to be that practice staff would log onto the enrollment system as the provider, but now accounts for credentialling are specific to the person using the account. This means staff cannot electronically sign as the provider and the practice ultimately needs the provider’s electronic signature. Six months later, providers who thought they were enrolled found out the process was never fully finished. The confirmation they kept was only for the staff’s part of the process.

On that topic, Medicare enrollment account access is made through the Identity & Access Management System (I&A). As I mentioned, in the past many folks would enroll as the provider; CMS does not prefer this. With an I&A account, staff go in as themselves to set up an account and then request the provider to grant access for them. Then they can continue to track details and timelines for the provider.

A word of caution when using this process: Be sure that when someone leaves the organization, that person’s access to the provider is removed!

Another point I cannot stress enough is ensuring you are correctly entering NPIs into your system. I know of a practice with two ASC locations, and one location’s NPI was not properly entered into the system for 11 years! Thankfully the ASC was able to work with a Medicare rep to rectify the situation.

Also know that with all the practice mergers and expansions happening across the country, errors can occur due to practicing in multiple states. I worked with a provider practicing in two states (crossing state lines), which required enrolling with more than one MAC. Since the MACs were different, there were separate enrollment records. One was revalidated, and the other was overlooked and ended up not being revalidated. This same issue can arise with providers who are performing surgeries in a hospital and other locations. If you have a provider who is a member of multiple practices, you will want to ensure the person responsible for revalidating this provider is revalidating for all the locations where that provider practices.

Lastly, when practices are acquired, each situation is unique. Generally, the entities were all separate, and now they want to be under one tax ID. Think about the timing and plans for the old entity (ie, is it going away or being absorbed, etc). There are a lot of variables to consider. I recommend working with a health-care attorney in these situations. OM

Laurie K. Brown, MBA, COMT, COE, CPC, CPMA, LSSYB is a senior consultant with BSM Consulting in Tucson, Ariz. She has experience in the ophthalmic industry holding managerial, clinical and surgical roles for more than 37 years.