Billing under SSN vs TaxID

[s_dipity]

We have a small practice of psychologists with a single provider. The practice has its Group NPI and Tax ID. The provider has the individual NPI and SSN.  The provider is a network provider with Aetna but the group is not ( we are trying to get the group on network, but I'm sure you know how long and painful that is). The provider provided services under the group umbrella. Now, if we bill using the Group NPI and Tax ID we will get the out-of-network provider benefits, but if we use the individual provider's SSN for the billing to get the network benefit, the reimbursement will be the income for the provider and not for the group.

I will appreciate if you could please guide me in the right direction in the current situation.

[Michele]

You are correct, if you want to get reimbursed the in network benefits then you would have to bill under the provider's name, ss#, and individual NPI.  But the payments would go directly to the provider and be reported to the IRS under the individual's ss#.  But if you bill under the group tax ID & NPI then the claim will be processes out of network.  You either have to bill under the individual and figure out a way to work out the payment problem, or the patient will be responsible.  There is no 'magic answer', unfortunately.

Sorry 

Michele

[Pay_My_Claims]

i'm not 100% sure on that.  I worked at a hospital where the hospital was OON but the provider was in. The hospital charges were processed as OON, but the provider was paid in net. I have also had the reverse. When I went in for a procedure, the hosptial was in net, but the provider was out. From what I know if a provider is within a group, you still put the group npi on box 32a and the individual in 33a Also you can put the individual provider NPI on each detail line. this lets the carrier know that although the "group" itself isn't in network, the individual is a network provider...the claim still should get processed in net and payment made to the group. I will try to find more information or maybe we will get more feedback on this case for u

[s_dipity]

Thanks Michele and Pay_My_Claims for your response. I will greatly appreciate if you could please find out a way to handle this situation. I am at a total loss.

Thanks again

[Pay_My_Claims]

I think if you put the providers individual npi on line 24j (detail line) and the group's taxid # in 25, the group npi# on 33a that should be ok. Payment will still come to the practice, but should be paid in network since the individual provider is in net. It would be similar to that provider performing services at an out of network hospital. The hospital gets paid OON for the technical charges but he gets paid innet for the proffessional charges. You can always call Aetna for more clarity.

[s_dipity]

Thanks. That's a big help. I will keep you posted how the things work out.