Key Takeaways
- Most insurance companies, including Medicare, will not pay for services provided by a non-credentialed doctor. This can lead to denied claims and a major loss of income for the practice.
- If a non-credentialed provider sees a patient, that patient may get stuck with the entire bill. This can damage their trust in your practice and harm your reputation.
- Treating patients without the right credentials can also lead to legal and compliance issues, which could result in fines or other penalties.
- To avoid these risks, the best approach is to start the credentialing process early or hire a professional service to handle the paperwork, which can help get approvals faster.
Imagine you’re running a healthcare practice. Your busy clinic hires a qualified new doctor. Patients are eager to book appointments, but the doctor’s credentialing isn’t finished yet.
Now, you’re left wondering—can the doctor see patients before everything is approved? What risks and rules do you need to watch out for?
In this article, we’ll explore real-world situations where non-credentialed providers might see patients, the possible risks your practice could face, and the rules you need to follow to stay compliant.
Whether you’re a provider or a practice manager, this guide will help you understand what’s allowed, what’s not, and how to protect both your patients and your business while waiting for credentialing approval.
What is Provider Credentialing?
Provider credentialing is the process healthcare organizations use to verify a provider’s qualifications.
This includes checking their education, training, licenses, and work history to ensure they meet the necessary standards.
The process typically involves submitting an application with all required documents for credentialing, verifying directly with the issuing institutions, conducting background checks for any malpractice or disciplinary issues, and reviewing everything through a credentialing committee.
Insurers and healthcare organizations require credentialing to maintain patient safety, ensure quality care, comply with regulations, and allow providers to join insurance networks and receive reimbursement for their services.
Can Non-Credentialed Providers Legally See Patients?
Yes, non-credentialed providers can legally see patients, but only under certain specific circumstances.
These include situations where the provider has temporary or provisional credentialing status, is working under the direct supervision of a credentialed provider, or is seeing patients during emergencies.
Other cases include out-of-network care, where patients agree to pay higher out-of-pocket costs, and telemedicine, provided the necessary state licensing rules are met.
However, these exceptions come with important legal and compliance boundaries. Providers seeing patients without full credentialing risk insurance reimbursement denials, potential liability issues, and regulatory penalties.
It is crucial to understand these rules to protect both the provider and the healthcare practice while waiting for official credentialing.
When Can Non-Credentialed Providers See Patients?
Not all waiting means no work!
Here are common situations where providers can see patients before full credentialing is done:
1. Temporary or Provisional Credentials
Think of this as a “fast pass.” Sometimes new providers get a temporary green light to start treating patients while their full paperwork is being processed.
This usually lasts a few months, but you should know that it’s not guaranteed for insurance payments. If the full credentialing takes too long, reimbursement might get stuck in limbo.
2. Supervision by a Credentialed Provider
Non-credentialed providers like nurse practitioners or physician assistants can work under the supervision of a fully credentialed doctor.
It’s called “incident-to” billing, where the supervising provider signs off on the care, and insurance reimburses under that provider’s name. It’s Kind of like an understudy stepping into the spotlight, but with the lead actor always on stage.
3. Emergencies
In true emergencies, care can’t wait. Even if a provider isn’t credentialed yet, they can jump in to help.
Insurance companies understand this and usually cover emergency services. But you should not try this for routine visits, as only urgent care counts during the insurance claims.
4. Out-of-Network and Self-Pay
Sometimes patients decide to see providers who aren’t credentialed with their insurance.
In this case, the patient pays out-of-pocket. This can mean higher costs and potential surprises for both the provider & the patient. That’s why clear and honest communication is critical.
5. Telemedicine and Crossing State Lines
Telehealth opens new doors, but also new rules. A provider might be licensed in one state but not fully credentialed with the patient’s insurer or in the patient’s state.
Many payers are flexible with telemedicine, but states and insurers have their own policies. So make sure to check the fine print before logging on.
Pro Tip: Every state and insurance company has its own credentialing quirks—always double-check before moving forward to avoid headaches later.
Risks of Seeing Patients Before Credentialing
Seeing patients before a provider is fully credentialed can cause serious problems for both the provider and the practice.
Insurance Reimbursement Denial
Most insurance companies, including Medicare, will deny payment if care is provided before the credentialing process is complete.
This means the practice may not get paid for services already delivered, which can lead to financial losses and administrative headaches trying to correct denied claims.
Patient Out-of-Pocket Costs
If a provider isn’t credentialed, insurance may refuse to cover the cost of their services. Patients end up receiving surprise bills, which affects their trust and satisfaction.
Clear communication about these costs is essential, but doesn’t always prevent frustration or patients from looking elsewhere.
Compliance and Liability Concerns
Treating patients without proper credentialing can put providers and practices at risk of violating regulations. This could result in legal penalties or fines.
Additionally, malpractice insurance might not cover claims related to care provided while credentialing is pending, exposing providers to personal financial risk.
Damage to Practice Reputation & Patient Trust
Billing denials and unexpected patient costs can harm your practice’s reputation. When patients feel misled or face unexpected expenses, it impacts the relationship and can drive them away.
Maintaining trust is critical, and ensuring providers are credentialed before seeing patients is a key part of that.
In short, seeing patients without credentialing might seem necessary at times, but it comes with risks that can affect your practice’s finances, legal standing, and patient relationships.
Why Proper Credentialing Matters?
Proper credentialing is more than just a formality—it’s essential to protect both providers and patients. Without it, providers risk delayed or denied payments, legal complications, and damage to their professional reputation. In fact, practices lose an average of $7,000 per provider, per month while waiting for credentialing approval, according to a recent study by the Medical Group Management Association (MGMA Credentialing Stats).
Patients also face risks such as receiving care from unverified providers or unexpected medical bills. With 91.2% of Americans having health insurance (US Census Bureau, 2023), delays in credentialing can directly impact a patient’s ability to access covered healthcare services. Furthermore, 87% of patients say they prefer credentialed providers, showing that proper credentialing helps maintain public trust (AMA Survey 2023).
Starting the credentialing process early gives providers ample time to complete necessary paperwork and verifications, avoiding costly interruptions in practice. Working with experts or specialized credentialing services can simplify this complex process. These professionals understand the requirements, help avoid common pitfalls, and ensure smoother, faster approvals.
Before seeing patients or submitting claims, it’s wise to consult a credentialing service, review your policies, or engage your compliance team. Taking these steps safeguards your practice and helps maintain the trust and safety that your patients expect.
FAQ
No, insurers—including Medicare and private payers—generally will not reimburse claims from non-credentialed physicians. Billing before credentialing is complete usually results in denials and potential compliance issues.
Most payers do not allow backdating of claims for services provided before the effective credentialing date. Submitting claims for those periods may be seen as fraudulent and could result in recoupments or penalties.
To speed up credentialing:
Begin the process early.
Submit a complete application with all documents.
Respond quickly to payer requests.
Consider professional credentialing services for faster follow-ups and fewer errors.
Yes, if they have a valid medical license and DEA registration (where required), they can legally prescribe. However, prescriptions may not be covered by insurance if the provider isn’t credentialed or in-network.
No. Billing under another provider’s NPI for services performed by a non-credentialed provider is considered fraudulent billing. This can trigger audits, legal penalties, and damage to the provider’s reputation.