We know how important continuity of care is for patients, but what about credentialing? Why is it so important to have the same individual be responsible for this important task? There are many reasons it is beneficial to have one person/business responsible for your credentialing over time, including protection (identity theft), ability to spot issues, and accountability.

I get a lot of clients that come to me that think they need billing clean up when in fact they need cre-dentialing clean up. Without this foundational piece being done correctly, there is no point in sending claims, because if the information is not correct in the payer’s database, your claims could reject without process¬ing, process incorrectly, or even pay to an incorrect address. All of these can be expensive errors.

Let me tell you a story about a long-time client of mine. After a few years of helping him with credentialing and later with billing, I helped him open his own practice, and in doing so, I updated address and information with all of the payers. Coincidentally, the practice was due for reval¬idation with Medicare at the same time as the move, and thankfully it all updated without any delays in reimburse¬ment. This client was a solo practitioner, which made any income delays especially hard.

Months went by and the practice was growing. One day, a Medicare representative called the office stating that there was an issue with the PTAN for the practice since they had moved locality and they would have to reissue a different num¬ber. We made the notation and had no issues as with the imple-mentation of NPI; we only used a PTAN when calling Medicare for claim status and other information. After a couple of months, we got another call stating they had made a mistake and we got another PTAN. We received notification that our revalidation was a success. Things continued to process properly and the end of the year came and went.

In the spring of the following year, we received a request for approximately $35,000 to be refunded. After many calls to Medicare, I was told there was an issue with the claims being processed under an incorrect PTAN. I was told that they wanted the practice to refund the entire amount and then simply refile the claims using the correct PTAN. I explained to the represen¬tative that providers no longer use a PTAN on a claim and was told “Oh well, just refile them then.” I stated I would not do that as some of these are over a year old and that since I would not be changing a single thing on the claim that these would all deny as duplicates. She really had no answer for me nor did the supervisor or the supervisor’s supervisor. The department that handles refunds was of course totally separate and they did not seem to communicate well among themselves.

Of course, as fate would have it, this coincided with my high-risk pregnancy and delivery of my daughter. To add to the problem in this small office, the two staff members unexpectedly quit, because they did not want to be left during my maternity leave. Being the “problem solvers” we were, we put out a distress call and some amazing family members came to the rescue to help cover the office for a few days while I delivered the baby and prepared to bring her back to work with me. The provider remembered that his malpractice covered “administrative” issues and suggested we throw this matter to the attorney to handle. What a relief, or so I thought.

The attorney immediately hired a consultant that was a fraud/ abuse auditor and specialist. The consultant decided that there was a mistake in the revalidation process. She felt that they needed to re-do the 855 with attention to the questions asking, “Have you been convicted of a felony?” even though I assured her they were answered and answered correctly on the one I submitted. When I asked her for the call reference number and to whom she spoke, she did not have an answer. I asked, “REALLY??????” I pointed out that while she was get¬ting up to speed, Medicare had offset the funds they requested and had begun to reprocess and pay the claims. If fraud was a problem, they would not be reprocessing claims on their end and they certainly would not be paying the current year’s claims without issue. We just simply needed to find a way to make them reprocess them faster and correctly. First Coast Service Options, our fiscal intermediary, was reprocessing these claims, and as I suspected, some were denying for timely file. I was calling the claims department and they were man-ually processing them to get them paid. The response from the consultant was to tell me to immediately stop working on the claims that were being denied for timely file. The attor¬ney even called to tell me to “Stay out of it.” This was super time-consuming for me, but my bigger fear was that if some¬one sent in an incorrect 855 at this point, our current income would stop.

I realized that I had just submitted our meaningful use attes¬tation and I was concerned this would be affected. I men¬tioned this to the attorney and he assured me they were han¬dling it and he told me that I should not do anything else.

I could be silent no longer. I went to the provider and told him my concerns. He heard me out and called the attorney and told him to fire the consultant he had hired. We simul¬taneously received a deposit for his meaningful use in the amount of $300 as opposed to the $1800 it should have been. This was crushing to this new practice, a solo practice. We began to call to get this fixed and were told that since mean¬ingful use is a “bonus,” there are no appeal rights afforded. I began to reach out to attorney after attorney, only to be told that they would not touch it since the other attorney had “touched” it. How very frustrating. So I reached out to our state senator.

We continued to plug along, working on posting all these things in our software. You see, we had to post the “offset” and the repayment and/or work on the appeal if they incorrectly denied. There were many claims that had originally paid with interest, and when they repaid the claim, they did not repay the interest that was owed to the provider.

The senator that had begun to intervene had passed away. This was a crushing disappointment as we now had to start all over while still working on staffing a growing practice, train¬ing staff, and continuing with the day to day work that it takes to run a practice.

I reached out to every industry expert I could find, only to be told that nobody has ever won against meaningful use when they pay incorrectly. With my numerous calls, I finally found someone willing to take an email regarding the issue that we had with our incorrect payment. I sent in our appeal to them, and to my great surprise, they actually paid my client what they owed him.

Unfortunately, all these issues were more than a solo practi¬tioner could bear and the provider decided to close his private practice and join a group setting.

The point of this article, however, is that without knowing that there were these calls with the PTAN issue, I would have been at the mercy of this “expert consultant” and this provider could have walked away with a sinking hole of debt, as opposed to being able to decide to close with the luxury of time to deter¬mine where and what he would do next. If I had not been the one to have done the revalidation, I would have believed them. I would have allowed them to file another 855. We can only speculate what a bigger mess that would have caused, but I for one am grateful he never had to know.

Merrilee Severino, CPC, CMMP, NC, is the CEO of Your Business Medic, a national billing service and credentialing company. She has over 25 years’ experience in billing, coding, and prac¬tice management. You can reach Merrilee at 727-408-0225 msppmrc@gmail.com. www.yourbusinessmedic.com