Late August is when the fall hires become real. The residency graduate who signed in February finishes vacation and asks for a start date. The nurse practitioner recruited in July gives notice at her old job. The practice manager opens the credentialing folder and finds a signed offer letter, a CV, and nothing else. Then she calls us and asks whether the provider can see patients on October 1.
The answer is yes, the provider can see patients. Whether the practice can bill for those patients is a different question, and the answer depends on the payer and on the calendar. This article is about the calendar: what is realistic for a provider starting in October or November when the file opens now, what to do first, and how to run the schedule so that the delay costs as little as possible. It is not a general guide to enrollment delays; we wrote that elsewhere. It is the math for this specific, common situation.
Key takeaways
- A file opened in late August for an October 1 start will bill Medicare on time or close to it, some Medicaid, and most commercial plans only after the holidays. No service changes that arithmetic.
- Sequence beats thoroughness when time is short: CAQH and documents on day one, Medicare by day three, state Medicaid before its managed care plans, then commercial payers in revenue order.
- The scheduling template is where the money is saved. Build the new provider's first two months around the payers that are effective and route everyone else to enrolled colleagues.
- Billing under a colleague's NPI outside incident-to rules, or using locum modifiers for a permanent hire, is a false claim, not a workaround.
- Keep a held-claims list from day one so retroactive effective dates can be applied the day they arrive.
Counting backward
Payer processing times run from the date a complete application is received. Working backward from a start date, the question for each payer is whether there is enough time, and if not, whether retroactive billing will cover the gap.
| Payer type | Typical processing after a complete file | Retroactive billing | File opened August 27, start October 1 |
|---|---|---|---|
| Medicare (PECOS) | 30 to 60 days | Usually up to 30 days before the application receipt date | Submit by early September and the effective date will likely cover October 1 or come close |
| Medicaid fee-for-service | 30 to 120 days, by state | Varies; some states allow retro to the application date | Possible for October in fast states; expect November elsewhere |
| Medicaid managed care plans | 60 to 120 days, after state enrollment | Rare | December is realistic |
| Commercial plans | 60 to 120 days, plus committee cycles | Rare; some plans backdate to the committee approval date only | December to January |
| Medicare Advantage | Follows the carrier's commercial process | Rare | December to January |
| Hospital privileges | 60 to 180 days | Not applicable | Temporary privileges may be possible; full privileges in the new year |
Read the last column honestly. A provider starting October 1 with a file opened this week will bill Medicare on time or nearly so, will bill some Medicaid, and will not bill most commercial plans until after the holidays. No credentialing service changes that arithmetic, and any that says it can is describing something other than payer enrollment.
The first ten days
When time is short, sequence matters more than thoroughness. This is the order we work in.
- Day 1 to 2: the intake packet and CAQH. The provider completes the intake form and either creates or re-attests a CAQH ProView profile with the practice authorized to view it. Every document is uploaded the same day: license, DEA, board certificate or eligibility letter, malpractice face sheet, CV with month and year dates, government ID. If the provider is finishing residency, the malpractice face sheet and the state license are the usual holdups; find out today whether either is pending.
- Day 2 to 3: Medicare. The CMS-855I (or the reassignment via the 855R) goes into PECOS as soon as the license and NPI are confirmed. Record the submission date; the retroactive window is counted from the date the MAC receives a processable application.
- Day 3 to 5: Medicaid. State enrollment first, then the managed care plans. Some states will not accept a managed care application until the state ID exists, so the sequence is fixed.
- Day 5 to 10: commercial plans in revenue order. Rank the practice's commercial payers by revenue and submit in that order. The top three usually account for most of the money. Get the reference number for each application in writing.
- Day 10: the follow-up calendar. Every application gets a status check every two weeks, entered in the tracker with the name of the person spoken to. Applications without follow-up do not move.
Running the schedule while enrollment is pending
This is where practices lose or save the most money, and it is entirely within their control. The scheduling team needs a one-page list, updated weekly, of which payers the new provider is effective with. For the first two months, the new provider's template is built around that list.
- Fill the new provider's schedule with Medicare patients and any payer already effective. Route other patients to enrolled providers.
- Where a commercial plan is pending, schedule its patients for the new provider only into weeks after the expected effective date, and tell them why if the appointment moves.
- Use the new provider for the work that does not depend on enrollment: chart preparation, care gap outreach, the annual wellness visits and Medicare patients that enrolled providers could not fit, and building a panel through the Medicare side first.
- Keep a held-claims list for any visit that was seen before an effective date arrived, sorted by payer, so that retroactive dates can be applied the day they are granted.
A practice that does this well loses very little. A practice that lets the new provider see everyone from day one accumulates a pile of unbillable commercial visits and then asks whether they can be billed under someone else's name.
The shortcuts that are not shortcuts
We get asked about three every fall.
Billing under a supervising physician. Medicare's incident-to rules require the supervising physician to have initiated the plan of care and to be present in the office suite, and they do not apply to new patient visits or new problems. Commercial payers have their own rules and many prohibit it outright. Billing a new provider's independent visits under a colleague's NPI outside those rules is a false claim, not a workaround. Ask the payer in writing before doing anything of the kind.
Locum tenens. Medicare's reciprocal and fee-for-time arrangements (modifier Q5 and Q6) exist to cover an absent physician, not to onboard a new one. Using them for a permanent hire is misuse.
Writing off the visits as free care. Legal, but it teaches patients that the new provider is free and it hides the true cost of the late file from the owners. Track the unbillable visits as a number and put it in front of the partners; it is the best argument for opening the next file the day the offer is signed.
Special cases in the fall
Two calendar effects are specific to this time of year. First, the ICD-10-CM update lands on October 1, so a provider starting that day is learning a new practice and a new code set at once; make sure the favorites list she inherits has already been cleaned. Second, commercial plan years and many patients' coverage change on January 1, which is often when the commercial effective dates finally arrive. A patient seen in December under a pending plan and again in January under a new plan needs both eligibility checks, and the held-claims list from December may need to be re-run against the new coverage.
If the provider is coming from another group in the same market, ask each payer for a reassignment or location update rather than a new application. It is usually faster, and it preserves the provider's existing effective dates. This only works if someone asks.
Questions we hear
The provider starts November 1. Does that change anything?
It gives Medicare and fast Medicaid programs comfortable room and moves the commercial estimates into January and February. The sequence is identical. The extra month is worth using for hospital privileges, which are the slowest item on the list.
Can the practice speed up a commercial plan?
Occasionally. Some plans offer expedited credentialing for providers joining a group that is already contracted, particularly in shortage specialties, and some will backdate to the committee approval date. Ask the provider relations representative directly, and get any promise in writing. Our credentialing and provider enrollment service tracks each application's reference number, follow-up dates and effective dates in a shared dashboard so the scheduling team always has the current list.
The hospital says privileges will take four months. Can the provider start anyway?
In the office, yes; hospital privileges govern hospital work, not office visits. Two things to watch. Several commercial plans ask on the application whether the provider has admitting privileges or a documented coverage arrangement, so if privileges are pending, submit a letter describing the arrangement with a colleague who does have them rather than leaving the field blank and inviting a deficiency notice. And ask the medical staff office about temporary privileges for a provider joining an existing group; many bylaws allow them for a set period while the full file works through the committee cycle, and it is the one part of this process where a phone call from a department chair still moves things.
What to do this month
- Open a file for every provider with a signed offer, today, regardless of start date.
- Submit Medicare within a week of receiving the license and NPI, and record the receipt date; the retroactive window counts from it.
- Rank payers by revenue and submit in that order, recording reference numbers.
- Give the scheduling team the effective-payer list and rebuild the new provider's template around it.
- Start a held-claims list and review it every Friday until the last commercial effective date arrives.
