Medicaid insurance and new solo private practice

[geripsyched]

Hello! I am in the process of opening a solo psychiatric practice this summer and currently getting credentialed with some of the commercial insurers and Medicare. During this credentialing process, a blue cross blue shield agent said, "If you choose not to accept Medicaid Managed Care members, this would be for all health plans, not just for BC/BS. NYS doesn’t allow for providers to pick and choose what MMC policy they can and cannot accept, as it is all or nothing."

To my understanding, however, healthcare organizations also determine what plans they accept, and many physicians work for a variety of healthcare organizations, some of which do/don't take Medicaid. For instance, a physician may be credentialed with Medicaid and see Medicaid patients at a hospital for 3 days/week. However, that physician may work for a different healthcare organization for 2 days/week, an organization that does not accept Medicaid insurance. So, although the individual provider is credentialed in Medicaid, whether she sees Medicaid patients depends on the healthcare organization setting and its policies. (is this incorrect?)

My question is this - I recently formed a professional limited liability corporation (PLLC) that is independent of me and that I plan to bill through - it has its own NPI type 2 number, tax identification number, business accounts, etc. So, although I am individually credentialed with Medicaid and will continue to see patients with Medicaid when working part-time with the academic hospital, it seems strange that I would be required to accept Medicaid insurance while working at an entirely different organization (my PLLC). Any idea if it is possible to be individually credentialed with BC/BS and its Medicare and Medicaid plans but, for the group/PLLC contract, only have the PLLC credentialed with BC/BS and its Medicare plans? That is, can my PLLC be credentialled differently than me individually?

Thanks all! I tried to find the answer to this question on Reddit, this forum, and google but had limited success.

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[ObsequiousAplomb]

I admit I don't know fully how to answer your question. The one thing I can say is that you cannot bill medicaid patients cash rates if you accept medicaid at any location. So my understanding is that you don't have to accept medicaid everywhere, but that you can't see medicaid patients in any location that does not accept medicaid.

 

[splik]

I admit I don't know fully how to answer your question. The one thing I can say is that you cannot bill medicaid patients cash rates if you accept medicaid at any location. So my understanding is that you don't have to accept medicaid everywhere, but that you can't see medicaid patients in any location that does not accept medicaid.

This is totally state dependent, and in NYS (which the op apparently is) you can bill medicaid cash in your pp even if you accept it at a hospital or clinic. The issue above is about managed medicaid rather than FFS medicaid, and it sounds like they will just have to exclude patients with managed medicaid from their pp. I don't think this is a big deal since it's not that common for medicaid pts to seek private pay.

 

[B52slinger]

This is totally state dependent, and in NYS (which the op apparently is) you can bill medicaid cash in your pp even if you accept it at a hospital or clinic. The issue above is about managed medicaid rather than FFS medicaid, and it sounds like they will just have to exclude patients with managed medicaid from their pp. I don't think this is a big deal since it's not that common for medicaid pts to seek private pay.

Do you know if non-board certified or board eligible (but licensed) physicians can bill medicare and medicaid in NYS? Can't seem to find these regulations on google, thanks very much for your help!

 

[splik]

Do you know if non-board certified or board eligible (but licensed) physicians can bill medicare and medicaid in NYS? Can't seem to find these regulations on google, thanks very much for your help!

medicare is federal so the same regulations apply across states. You do not need to be board certified or even finished a residency in order to bill medicare. You just need to be registered with medicare. If you have an NPI as a physician and registered your practice through PECOS you can bill medicare.

For NYS medicaid, you need a physician NPI and an ETIN. You need to be fully licensed but don't need to have completed a residency or be board certified. They don't even ask for that information.

 

[B52slinger]

medicare is federal so the same regulations apply across states. You do not need to be board certified or even finished a residency in order to bill medicare. You just need to be registered with medicare. If you have an NPI as a physician and registered your practice through PECOS you can bill medicare.

For NYS medicaid, you need a physician NPI and an ETIN. You need to be fully licensed but don't need to have completed a residency or be board certified. They don't even ask for that information.

This was extremely helpful. Thank you very much for your time and help!

 

[splik]

This was extremely helpful. Thank you very much for your time and help!

You may also be interested to know that commercial insurance companies will often allow licensed physicians who haven't finished residency to become credentialed as a general practitioner. I have heard of some docs providing psych services this way. The rates they offer will be lower than for physicians who have completed residency or are board certified.

 

[B52slinger]

You may also be interested to know that commercial insurance companies will often allow licensed physicians who haven't finished residency to become credentialed as a general practitioner. I have heard of some docs providing psych services this way. The rates they offer will be lower than for physicians who have completed residency or are board certified.

Wow. Great to know as well. Thank you!

 

[B52slinger]

medicare is federal so the same regulations apply across states. You do not need to be board certified or even finished a residency in order to bill medicare. You just need to be registered with medicare. If you have an NPI as a physician and registered your practice through PECOS you can bill medicare.

For NYS medicaid, you need a physician NPI and an ETIN. You need to be fully licensed but don't need to have completed a residency or be board certified. They don't even ask for that information.

Does this include managed care and advantage plans? Thanks

 

[splik]

Does this include managed care and advantage plans? Thanks

No. For medicare advantage plans you have to both be registered with Medicare and the specific commercial insurances with the plans. They will usally have the same requirements (or greater) to credential with the commercial plan as for medicare advantage.

for managed medicaid plans, it would depend on the plan. If through a commercial insurance company then you would have to meet the requirements of that company.

 

[geripsyched]

Thanks everyone for your input! Appreciate it. Can see why people often go with billing companies for credentialing/etc.

 

[Coupd'Cat]

As an aside, a friend of mine in New York likes working with Headway as an insurance manager platform, if you haven't heard of it. I haven't used it personally, but it looks like they help coordinate both private insurance and Medicaid. Your Practice, Powered by Headway | Headway

 

[Sushirolls]

Thanks everyone for your input! Appreciate it. Can see why people often go with billing companies for credentialing/etc.

No, that is not the conclusion to take away.
Don't pay for credentialling services. It is a racket, and another poster on here lost 6K and got ghosted.
I paid, got credentialed, but they kept saying we can't do this form you have to.
So most every application I essentially did, and most every application they entered in details wrong and I fixed.

Just do it yourself. If you can apply, get in, complete and graduate from medical school, and then residency too... you can figure out getting paneled with insurance companies, too. Wrong data inputs could mean delays or not getting paid or not getting credentialed.

not something to outsource if going into Private Practice.