Not Credentialed Yet? Here’s How You Can Still See Patients

Waiting for a physician’s credentialing to be approved can feel like hitting pause on your revenue cycle, and in a fast-paced healthcare environment, that pause is costly. With the average credentialing process taking up to 90–120 days, many practices find themselves in a bind: how do you keep serving patients without risking compliance issues or delayed reimbursements? 

The good news is that there are legal, smart strategies to keep your doors open and steady cash flow while credentialing is in progress. Let’s explore how to deal with confidence and clarity.

What Is Credentialing In Healthcare?

Credentilaing in healthcare verifies providers’ qualifications, like their education, license, and experience, to ensure they’re eligible to treat patients and bill insurance. The verification of a provider’s qualifications, like their educational background, licensures and experience, is called Credentialing. This process ensures that the providers are eligible to treat patients and bill insurance.

Why is Credentialing Important?

If a physician isn’t credentialed, insurance companies, including Medicare, Medicaid, and private payers, won’t recognize them as authorized providers. That means:

• They can’t bill or get reimbursed for services rendered.

• Patients may have to pay out-of-pocket or may not be able to use their insurance at all.

• It can trigger compliance issues and raise red flags in audits.

Non-Credentialed and Non-Contracted Providers

Let’s start by clearing up the terminology:

• Non-Credentialed Provider: A provider who has not yet completed the payer’s credentialing or enrollment process. That payer does not recognize them to render reimbursable services.

• Non-Contracted Provider: A provider who is not part of the payer’s network. They may be credentialed but are considered out-of-network for that payer.

Common Scenarios Involving Non-Credentialed Providers

There are several situations where a provider might deliver care before they’re fully credentialed:

1. New Permanent Hires

A provider might accept a job offer and begin seeing patients while their credentialing application is still in process. This can happen due to:

• Staffing shortages

• Patient demand

• Long credentialing timelines (some can take 60-120 days or more)

In these cases, practices must decide how to bill for their services during the credentialing window if at all.

2. Temporary/Substitute Coverage

Practices frequently bring in temporary providers to cover for those on leave (e.g., maternity leave, vacation, medical absence). These “fill-ins” may not be credentialed or enrolled with certain payers but are needed to maintain operations. This is where locum tenens and reciprocal billing come into play.

Can You Bill for Services by a Non-Credentialed Provider?

Some commercial payers may allow retroactive billing if the healthcare credentialing application was submitted before services were provided. However, Medicare generally does not allow retroactive billing, except in very specific cases. 

Payer Type	Allows Retroactive Billing?	Notes
Medicare	Rarely	Only in specific hardship cases
Medicaid	Usually No	Rules vary by state
Commercial Payers	Sometimes	Depends on when the application was submitted and the policy terms

Billing Options for Temporary Non-Credentialed Providers

When temporary or short-term coverage is needed, there are two key billing mechanisms:

Locum Tenens Billing

Locum tenens refers to a temporary provider hired to substitute for another physician. Under Medicare, you may bill for a locum tenens provider using the NPI of the absent, credentialed provider, provided:

• The absent provider is unavailable (e.g., leave, vacation)

• The locum’s services do not exceed 60 consecutive days

• The claim uses the Q6 modifier to indicate locum coverage

Reciprocal Billing

This arrangement is used when two providers agree to cover for each other on a temporary, informal basis. If Dr. A covers Dr. B’s patients while Dr. B is unavailable, Medicare allows Dr. B to bill under their NPI using the Q5 modifier for up to 60 consecutive days.

As with locum tenens, this applies only when:

• The regular provider is unavailable

• The substitute is not providing care beyond 60 consecutive days

• The arrangement is temporary

Healthcare Credentialing seems difficult, but skipping it can cost providers more. In a system where 90% of the population relies on insurance to cover thier healthcare costs, you can lose patient access when you’re not credentialed.

Here’s what can happen if a provider skips or delays credentialing:

Loss of Reimbursement Opportunities

Without credentialing, providers are not authorized to bill Medicare, Medicaid, or commercial insurers. This leads to 100% loss of eligible revenue for insured services. According to the AAFP, three out of four claim denials are tied to credentialing errors.

Patient Retention & Access Challenges

Patients may choose another provider if insurance won’t cover visits. Credentialing delays can extend onboarding timelines by up to 60 days, impacting both cash flow and continuity of care (MGMA).

Legal & Compliance Risks

Delivering care without being credentialed may violate payer agreements or even state laws. This can open the door to audit penalties, lawsuits, or contract terminations.

Damaged Reputation and Patient Trust

Patients are more informed than ever. A provider who isn’t listed in insurance directories or who causes billing issues can suffer poor reviews and a drop in referrals, especially when 73% of patients use online reviews to choose healthcare providers.

Operational and Financial Disruption

The average credentialing process takes 90 to 120 days. Delaying it can block new hires from contributing to revenue, disrupt schedules, and increase administrative burdens.

Best Practices for Billing and Managing Non-Credentialed Providers

 To protect your revenue cycle and ensure compliance, follow these recommendations:

• Start Credentialing Early: Ideally, begin credentialing during the hiring process, not after the provider starts seeing patients.

• Know Each Payer’s Rules: Maintain a payer matrix or cheat sheet with credentialing and billing policies. These vary widely.

• Avoid Billing Prematurely: Don’t submit claims until you have confirmation of credentialing/enrollment from the payer.

• Limit Scope of Services: Until credentialing is complete, limit the provider’s work to services that are self-pay, not covered by insurance, or supervised by a credentialed provider (when applicable).

• Use Locum or Reciprocal Billing Only When Appropriate: Ensure the provider fits the criteria, and track days carefully.

• Document Everything: Maintain records of dates of service, credentials in progress, modifiers used, and internal communications.

Final Thoughts

Dealing with patient care when a physician isn’t yet credentialed can feel overwhelming, but with the right knowledge and strategy, it’s entirely manageable. By understanding payer-specific rules, using temporary billing options like locum tenens or reciprocal arrangements, and proactively starting the credentialing process, practices can avoid revenue loss and stay compliant. Credentialing may be time-consuming, but it’s essential for long-term growth, smoother operations, and building patient trust. 

Let us handle the paperwork so you can focus on what matters most—delivering care.
📞 Contact us today at (415) 508-6537 to speak with our credentialing support team.