Credentialing and Billing Golden Rules 002 300x300 | Wells Fargo, Whose Really to Blame? | STATMedCare Payor and Physician Enrollment and CredentialingBe Sure You Are Following These Credentialing and Billing Golden Rules!

Wells Fargo

We’ve all seen Wells Fargo in the news this week for creating thousands of fraudulent accounts. The bank was fined $185 million dollars for improper and illegal sales tactics on behalf of it’s employees.  While one could argue that the bank, at its highest level, must have known this was going on, others would argue the bank, as an organization, couldn’t have known.  Knowing what your employees are doing, and the laws surrounding the practices your staff employ, are imperative to running a successful medical practice.

What’s The Law?

Knowing laws related to your billing practices are particularly important. These laws revolve around your credentialing and how your credentialing was done with each payor. One cannot simply claim ignorance in relation to these laws. If you end up being audited you, as the practitioner, are on the hook for all claims you billed to insurance carriers.

Credentialing/Billing Golden Rules

To ensure you don’t end up fined, or in hot water with the federal government, ensure you are following the credentialing/billing golden rules listed below:

  • More than One (1) Location: If you practice medicine at more than one location each location must be listed with each payor (i.e. United Health Care, Cigna, etc.) on your payor contract. If you need help adding, or removing, practice locations, contact a credentialing professional.
  • Box 33: Box 33 of a HCFA 1500 (billing claim form) should ALWAYS be where your billing office is located. It should NEVER be where the service was rendered.
  • Box 25: Be careful with Box 25 – Federal Tax ID number. If you have multiple Tax ID numbers, you will need to place the Tax ID number you credentialed with – for that specific payor – into Box 25. So, if you credentialed TIN 661789153 with Cigna, and you are filing a claim to Cigna, you will need to place that TIN in Box 25.
  • Box 32: It is imperative that Box 32 – Service Facility Location Information – have the location where the service was rendered. This must be the physical address of where the service was rendered. If it was rendered at a patient’s home, the address will be the patient’s home address. If rendered at a hospital, use the hospital’s address. If rendered in your office, use the office’s address.
  • Box 24J: This box – Rendering Provider ID # – should ALWAYS be the NPI (National Provider Identifier) of the provider who actually treated this patient. You should NEVER put anyone else’s NPI there, even if you are being supervised by a supervising physician.

HCFA 1500 Form

Should you have any questions related to the boxes on the HCFA 1500, please consult with a credentialing professional who can help you ensure you are in compliance with all credentialing guidelines – both state wide and national. The link for the HCFA 1500 form is: http://4.bp.blogspot.com/-YcSeVyQNpc0/T8Rfn8jA_EI/AAAAAAAAAB8/zoUuhPNjEHU/s1600/hcfa+1500.bmp


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Cynthia Young, the former CEO of STAT, which is a U.S.-based, national provider of credentialing, payor enrollment, rate negotiation, and other credentialing related services.