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As graduation season brings a new wave of optometrists into the profession, many practices are eager to welcome fresh talent into their teams. While onboarding new graduates is exciting, it also comes with important administrative considerations—particularly around insurance credentialing and billing practices.
Most insurance companies will not reimburse for care provided by a doctor who has not yet been fully credentialed and added to the plan’s provider panel. During this interim period, it may be tempting to bill under the NPI of an already credentialed optometrist in the practice. However, this shortcut carries serious risk.
Even one patient calling their insurance company to question why their Explanation of Benefits (EOB) lists Dr. A when they were seen by the new graduate Dr. B can lead to an investigation into potential fraud. Such scenarios are not hypothetical—as evidenced by this 2020 case where a group of San Diego eye doctors paid $950,000 to settle allegations of Medicare billing fraud for submitting claims under the names of credentialed providers when an uncredentialed one had rendered the care.
Standard billing alternatives like locum tenens or reciprocal billing do not apply in cases where a provider has not been credentialed. Therefore, the prudent approach is to directly contact each insurance plan to verify whether billing is allowed for services rendered by a non-credentialed provider. If not, the safest course of action is to limit the new doctor’s work to self-pay patients and assistive, non-billable activities until credentialing is complete.
By setting clear expectations early and prioritizing compliance, practices can enjoy a smooth transition during this exciting time of year—while protecting themselves from unnecessary financial and legal exposure.
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Board members (l-r): Ken Kopolow, OD; Milissa Stone; Lisa Hamilton, OD; and Richard Hults, OD
Brooke Hawley
