Hiring a new physician is an exciting step for any practice—but what happens when the doctor is ready to work, yet still waiting for credentialing to finalize? In today’s complex medical billing environment, this is a common and frustrating situation.
You might be wondering:
Can a physician start seeing patients if they’re not yet credentialed?
The short answer is: Yes, but only under specific, carefully managed conditions.
The long answer involves understanding billing restrictions, legal risks, and payer-specific exceptions.
This article outlines what’s allowed, what’s risky, and what you can do to stay compliant while maintaining patient access and practice revenue.
What Is Medical Credentialing?
Medical credentialing is the process of verifying a healthcare provider’s:
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Education and degrees
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Licensure and board certification
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Work history
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Background and malpractice record
It’s a requirement for enrollment with Medicare, Medicaid, and commercial insurance networks. Without completed credentialing, a provider is considered out-of-network or ineligible for billing services to insurance payers.
Important: Most payers (especially Medicare and Medicaid) will not reimburse services rendered before the credentialing date.
Why You Shouldn’t Skip Credentialing
Seeing patients without being credentialed isn’t just a billing issue—it’s a legal and ethical risk. Here’s why:
1. Denied Reimbursements
Payers reject claims submitted under non-credentialed providers, even if care was medically necessary. This results in lost income for your practice.
2. Patient Billing Issues
Patients may be forced to pay the full cost of the visit, damaging trust and leading to poor reviews or complaints.
3. Malpractice Liability
If a provider who isn’t credentialed is involved in a lawsuit, insurance coverage may not apply.
4. Violations of Insurance Agreements
Billing under someone else’s name (fraudulently or mistakenly) can lead to payer audits, fines, and legal action.
When Can Non-Credentialed Physicians See Patients?
While generally discouraged, there are five specific situations where it may be permissible if done correctly.
1. Provisional or Temporary Credentialing
Some insurance payers offer provisional approval, allowing a new provider to begin working while the full credentialing process is still underway.
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Typically used in hospital or large group settings
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Often limited to 60 to 120 days
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Requires a submitted, clean application and background check
Important: Not all payers offer this. Check with the specific plan before proceeding.
2. Under Supervision of a Credentialed Provider
In some settings, non-credentialed providers can work under supervision from a fully credentialed clinician. This is common for:
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New hires (such as residents or fellows)
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Nurse Practitioners and PAs
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Physicians awaiting approval
In these cases, the supervising provider bills for the services performed by the non-credentialed provider. The claim must reflect the supervising provider’s NPI.
Note: Documentation must clearly indicate that services were supervised, and the level of supervision must meet payer rules (general, direct, or personal supervision).
3. Emergency Situations
In true emergencies—such as disaster responses, provider shortages, or sudden health crises—a non-credentialed provider may be allowed to treat patients temporarily.
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Applies in urgent care, ER, and hospital settings
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Must be clearly documented
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Should not be used as a long-term workaround
Tip: Keep detailed records to support that care was necessary and time-sensitive.
4. Self-Pay or Out-of-Network Care
If a physician isn’t credentialed, they can see self-pay patients or out-of-network patients—provided those patients understand and agree to the arrangement.
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Obtain signed patient consent acknowledging the physician is not in-network
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Be transparent about costs
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Do not submit claims to payers unless explicitly allowed
This approach can work for concierge practices, behavioral health, or boutique clinics that operate outside traditional insurance networks.
5. Locum Tenens or Substitute Physicians
Medicare allows locum tenens physicians to substitute for a credentialed provider temporarily—under certain rules:
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The absent provider must be credentialed
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Services must be billed using the regular provider’s NPI with modifier Q6
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Duration is limited to 60 days per incident
This is not a solution for onboarding new hires but can be used for vacations, illness, or other short-term gaps.
What You Should Not Do
Here’s what to avoid at all costs:
Billing Under Someone Else’s NPI Without Proper Supervision
This is considered Medicare fraud, even if it’s done unintentionally.
Backdating Claims
Payers do not allow claims to be submitted for services provided before credentialing approval. Doing so can trigger audits and repayment demands.
Assuming “They’ll Approve It Later”
Even if you expect credentialing to go through, care delivered before official approval is not covered by most insurers.
Best Practices to Avoid Gaps in Service
To minimize the time a provider waits to see patients:
Start Credentialing Early
Begin the process 90 to 120 days before the provider’s first day on the job.
Submit a Clean Application
Double-check for errors, omissions, or expired documents.
Follow Up Consistently
Credentialing requires regular communication with payers. Don’t assume silence means progress.
Use a Credentialing Specialist
Outsourcing to an experienced credentialing company like CloudRCM Solutions can reduce delays, avoid rejections, and help you stay compliant.
How CloudRCM Can Help
At CloudRCM Solutions, we handle every step of credentialing—from CAQH profile setup to Medicare, Medicaid, and commercial payer enrollment.
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Fast-track credentialing for new hires
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Maintain compliance with all payer rules
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Minimize reimbursement delays
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Handle re-credentialing and updates
We specialize in helping solo providers, group practices, and behavioral health clinics across the United States.
Call us today: (415) 508-6537
Visit: www.cloudrcmsolutions.com
Based in Park Ridge, IL 60068 — Serving practices nationwide
Final Thoughts
It is possible for a non-credentialed physician to see patients in specific, limited situations—but doing so requires clear policies, payer communication, and airtight documentation. Don’t risk reimbursement losses or compliance violations by cutting corners.
When in doubt, get credentialed first—or consult a credentialing expert who can guide your practice safely through the process.
