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Guidance on how to bill when doctors are not yet credentialed
By Joe DeLoach, OD, FAAO
July 9, 2025
“We added a doctor from another practice or hired a new grad – how do we file for their services since we have not had time to credential them?”
This is a question received by our firm, Practice Performance Partners (PPP) all the time – and a frequent one on optometry blogs. Once again, much of the information floating around is simply incorrect.
The first and most common advice found is – simply bill non-credentialed doctors under the credentials of another doctor in the practice. After all, everyone does it that way. Reminds me of the age-old parental advice about following your friend’s lead – “If Joe jumped off the cliff would you do the same?” A “yes” answer is wrong – in both cases. Payers have strict rules about services being billed ONLY by credentialed doctors. The penalties for breaking those rules can include a return of all fees received incorrectly and removal from the provider panel.
Let’s look at the right way to do this. The best-fit answer is – you cannot bill services to payers until a doctor is credentialed. It can be a little more complex, but not much. Here are the three scenarios.
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The new doctor is billing for self-pay care
No problems. They can do that immediately.
The new doctor is going to be a permanent hire – full or part-time
- Vision Plans: Read the provider manual. Most vision plans state that doctors must be credentialed before they provide services. VSP states you can bill the new or temporary doctor under another credentialed provider if the rest of the group is credentialed but only for a very limited time (VSP must pre-approve any time period beyond 10 days). EyeMed requires doctors be credentialed…period. Don’t push your luck – vision plans are often more serious about this issue than any payer.
- CMS (Medicare/Medciaid): Doctors who are full- or part-time hires must be credentialed in order to bill for their services. Period.
- Advantage Plans all have their own rules but most require doctors to be credentialed. Again, refer to the provider manual.
- Major Medical Plans: You should look at each individual contract. Most follow Medicare’s lead on this, but some will allow immediate billing for a new provider in a group already credentialed with the plan. If that is their policy, you would likely have to inform the payer of the new addition.
- A few states have rapid credentialing laws in place that allow you to file a new doctor under a currently credentialed doctor as long as you are making a concerted effort to get the new doctor credentialed. These laws do not apply to Medicare, Medicaid or Advantage Plans. Check your state association for details.
The new doctor is going to be a substitute provider for a TEMPORARY period
This one can be tricky. Some like to call this locum tenens, but locum tenens rarely applies outside of CMS-controlled plans and has very strict requirements that severely limit its use. The credentialed physician is allowed to bill and receive payment for a substitute physician’s services as though the credentialed physician performed them but only if the following apply:
- The “regular” credentialed physician has left your practice and is unable to provide services.
- The “regular” credentialed physician is not available to provide care (meaning they are absent from the practice – not just that their schedule is full).
- Locum tenens can only be used for 60 days from the date the new physician sees the first patient.
- The non-credentialed physician under locum tenens must be paid on a per diem basis with no productivity incentives.
- Locum tenens cannot be used for a new physician hired by the practice (by definition locum tenens is a temporary situation where care is provided by someone outside the normal physician team).
- Locum tenens does not apply to a new physician hired to work at a new satellite office – because there is no physician they are replacing or filling in for.
Medicare Advantage plans and major medical plans can have their own individual rules regarding locum tenens. A general statement is that most major medical plans do not allow it. If locum tenens applies, although it rarely does, you bill under the credentialed doctor’s NPI that the doctor is “filling in” for and attach a Q6 modifier to every service provided.
How about “checking in”? Common advice is for the credentialed doctor to review the non-credentialed doctor’s charts and “sign off” on them. This accomplishes nothing. There are no laws that allow simply reviewing a chart as a substitute for the actual provision of services. At a minimum, the credentialed doctor must meet the patient and perform some degree of physical examination – in other words, you must establish a doctor-patient relationship. Even this scenario is considered by many to be on shaky ground.
Bottom Line Moral of the Story
Make all efforts to get your new doctors credentialed under every payer plan as quickly as possible. Your ability to legally file services for non-credentialed physicians is very limited.
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Joe DeLoach, OD, FAAO, is chief compliance officer for Practice Performance Partners (PPP) and former Clinical Professor at the University of Houston College of Optometry. To contact: joe@practiceperformancepartners.com
