Medical Billing Forum

NPI Numbers => NPI Numbers => Topic started by: jcbilling on September 13, 2008, 02:57:34 PM

Title: Group or Individual NPI
Post by: jcbilling on September 13, 2008, 02:57:34 PM
Hello everyone!

First, I wanted to tell Alice & Michele how much I appreciate this forum and their resourceful website. It is very encouraging to me to have it available.

Secondly, I recently signed a contract with 4 doctors - three are chiropractors and one is a family practitioner. There are three locations, with the main chiropractor and family practitioner practicing in the same office and the other two chiropractors have two separate locations. The main chiropractor asked if they need to bill under a group NPI or individual NPI. Right now, all the family practitioner's claims are under his NPI, but they practice in the same building. He recently left the local hospital to practice with the chiropractor.  All four of the providers have individual NPI's, but one currently bills under the main chiro's NPI - which I told him I didn't think was right - he agreed.

Now that I have everyone confused, myself included :) how do I find out how it ought to be done - group or individual?

Also, the family practitioner was credentialed with local hospital and has a Medicare number. Does he need to do anything to become credentialed to practice in the new location. They want to be in network with BCBS only.

Thanks so much!

 - Charity
Title: Re: Group or Individual NPI
Post by: Michele on September 13, 2008, 04:35:19 PM
Hi Charity,
   So glad you like our website/forum.  We love to hear it. 

Regarding the 4 drs, if they all bill under one group name and tax ID# then you would bill all under one group npi number in box 32a and 33a.  But you would use their individual NPI #'s in box 24J to show the rendering provider.  However, you must make sure all providers are 'linked' to the group NPI with the insurance carriers you are billing for. 

If the family practitioner was credentialed with the hospital you need to make sure he is now credentialed under the group he is with.  He doesn't need to start from scratch, he just needs to notify the insurance carriers that he has left the hospital and joined a group.  If he doesn't want to be a Medicare provider anymore he should deactivate his Medicare number.  However, if he is considering taking Medicare at the new location, then he just needs to notify Medicare that he switched locations.  He would do that with an 855I form.

Michele
Title: Re: Group or Individual NPI
Post by: jcbilling on September 17, 2008, 01:31:18 PM
Thank you so much Michele! I appreciate your willingness to help and for making my complicated question so simple :)

I do have a follow-up question: Do I need to have all 4 doctors sign a contract? or just the head of the group?

 - Charity
Title: Re: Group or Individual NPI
Post by: Michele on September 17, 2008, 09:05:36 PM
If you mean a contract with you as a billing service, you just need one person to sign for the whole group.

No problem, we love to help!

Thanks
Michele
Title: Re: Group or Individual NPI
Post by: LW5689 on October 06, 2008, 11:08:11 AM
Michele,
I am going to begin billing for a PT and I am somewhat confused about exactly where to put his NPI#.  I believe I need to put it in 24J and 33a but wasnt sure if I needed to put it in 32a?  He treats patients at a few different facilities and I just wasnt sure if I needed to put his NPI in 33a or if a separate facility NPI goes there?  Thank you so much.  Lori
Title: Re: Group or Individual NPI
Post by: Michele on October 06, 2008, 07:24:04 PM
You want to put the NPI of the provider performing the service in box 24J (the physical therapist) and the NPI of the where the reimbursement goes in box 33a.  So if the PT is a solo provider billing under his own name (not a group name and tax ID) then you would put his individual NPI in 33a.  Now, box 32a is suppose to be the corresponding NPI for the facility name in box 32 so if the physical therapist is billing under his own name and only has an individual NPI, and has multiple locations in his name, it would be his individual NPI. 

I hope that is helpful and not more confusing!    :-\

Michele
Title: Re: Group or Individual NPI
Post by: LW5689 on October 07, 2008, 10:18:52 AM
Michele, I think I am getting it.  But what if the therapist is in addition to his own facility renting space from other proviers would I still put down the treating facility location but with his individual NPI #? in 32a  I thought that the individual NIP # goes anywhere the provider would go?  Forgive my ignorance.
Title: Re: Group or Individual NPI
Post by: Michele on October 07, 2008, 09:05:47 PM
It's not ignorance, that is a good question.  If the PT is credentialed to practice at these different locations/facilities, then even though the facility is not owned by the PT, he technically has a location at that facility.  So you would enter his name, the facility address, and his NPI in box 32.

It's like he subrents space at the facility that he has his own little private practice at (even though it is not 'his' space and he is using their equipment.  I'm just trying to show you what I'm saying.).

Hope that helps.
Michele
Title: Re: Group or Individual NPI
Post by: jcbilling on October 13, 2008, 09:12:02 AM
I have a follow-up question about NPI's!

If all the dr's NPIs are linked to the group, does it matter what address is on their individual NPI's? or do they need to update their individual NPI's to reflect their practice address? How do you link the dr's to the group NPI - two of them are currently not linked.

Thanks so much!

 - Charity
Title: Re: Group or Individual NPI
Post by: LW5689 on October 13, 2008, 11:07:55 AM
Can a provider who has an individual NPI # also be part of a group and have a group NPI #?   Or is it one or the other? Can a provider bill  individually if he provides services separately from the group at times?
Title: Re: Group or Individual NPI
Post by: Michele on October 13, 2008, 12:37:40 PM
The address on the NPI system does not affect the payment if payment is going to the group, but the provider should have accurate info on the NPI system.  You would need to contact the insurance carriers to have the providers credentialed under the group.  That will link their individual NPI to the group.  Also, if the provider is credentialed with both a private practice and under the group (billing under different tax ID's) then they can bill their private practice under their individual NPI and the services with the group using the group NPI (with their individual NPI as the rendering provider). 

Many doctors have both an individual and a group NPI.

Michele
Title: Re: Group or Individual NPI
Post by: jcbilling on November 24, 2008, 01:39:40 PM
Michele,

One of the DC's that is not linked to the group is currently billing under the main dr's individual NPI # - which I know is wrong and I'm trying to correct. First, the dc needs to fill out a CMS 855R to be linked to the group, right?
But until that happens, I'm considering billing under his individual NPI. The only problem is that he works out of another location in another city part time -and that is the address that his individual NPI reflects on the Enumerator system. So if I submit claims with his individual npi, how do i keep payments from going to the part time office and instead come to the office where I do the billing for? I'm thinking it's the facility address, but I'm not sure.

Do you have any suggestions?

Thanks,
Charity
Title: Re: Group or Individual NPI
Post by: Michele on November 25, 2008, 09:48:17 AM
If you bill under that Dr's individual NPI  before you link him to the group the claims will probably be denied stating that the ind provider wasn't eligible to bill under the group on the date of service.  If they do pay, it will go to the private practice, not your group.  There is no way around that without doing the 855R form.  Just date it for when you need to start billing, then hold claims until the 855R is processed.  That would be the best way to go.

Michele
Title: Re: Group or Individual NPI
Post by: mbenedict on February 02, 2009, 07:14:08 PM
Hi, I'm Marjie and I work for an optometrist that accepts Medicare.   I just completed the mess of paper work required by MCare for a change in the doctor's tax status from sole proprietor to Inc. PA.  I finally got the go ahead, the changes and requirements from MCare had been met so I then billed the claims I needed to.  MCare rejected every one and I'm confused as to how to use the NPI attaced to the doctor herself and the group NPI.  I filled out 24 J with her personal pin and box 32 & 33 with the group pin.  It's only one doctor, so should I use the group NPI that is attached to her new tax ID in 24J and 32, 33? thank you for any help. (I have talked to mcare reps and read the online instructions in the mcare manual and I get different answers!) 
Title: Re: Group or Individual NPI
Post by: Michele on February 03, 2009, 05:37:07 AM
If Medicare has assigned the dr a group PTAN for her group name and group NPI, and an individual PTAN under her individual NPI, then you would bill with her individual PTAN in box 24J and group PTAN in 32 & 33 A.  But if Medicare only assigned 1 PTAN, then it would be different.  You would need to leave 24J blank and use the NPI that Medicare is using in 32 & 33 A.  When Medicare updated your changes they should have sent you a letter advising you of the update and showing the PTAN, NPI and tax ID they currently have on file.  If you don't have that letter, call Medicare and ask what NPI they have linked to the dr's PTAN.  Even though we don't use PTAN's on the claim anymore they are still a big part of billing.

Michele
Title: Re: Group or Individual NPI
Post by: powerbilling on March 24, 2009, 06:46:27 PM
Hi Michele,

I just wanted to thank you so much for your knowledge. I've been running a medical billing company for about 8 years now and over the last year have had nothing but issues with Medicare, Blue Shield and Blue Cross and the Group NPI # for Box 33A. After reading thru your posts I found my answer, and fixed the problem. What has taken me a year to try to fix I was able to fix in less than 30 minutes doing some research with your site and verifying with my software company.

I will be checking out the posts here every week! Great work! Thanks again!

Michelle P.
Title: Re: Group or Individual NPI
Post by: Alice Scott on March 25, 2009, 05:44:27 AM
Michelle,
Thanks for your kind words.  We're glad we could be of help.  We all run into problems no matter how long you are in this business and we believe this is the way to help each other. 
Alice
Title: Re: Group or Individual NPI
Post by: PMRNC on March 25, 2009, 06:08:13 AM
NPI was a big pain in the butt for all of us I'm sure. The biggest problem I seen was the doctors not UNDERSTANDING how the NPI application and info had to match their IRS file. The second biggest problem I had were with a few clients that were using the same clearinghouse and we found out the errors were on their end. I still have one provider with an issue that is split   ::)
Title: Re: Group or Individual NPI
Post by: Michele on April 17, 2009, 09:27:04 PM
This drives me crazy too.  I had a dr today that is trying to update their info with Medicare and the NPI (Type II) doesn't match the business name exactly.  The dr is crying that Medicare is being ridiculous.  I tried to explain, but ahhhh  --  it just doesn't sink in.  :)

Michele
Title: Re: Group or Individual NPI
Post by: thatcuteblonde on October 07, 2009, 02:58:50 PM
I wanted a quick add on to this, I have Medisoft, same scenario. Set up a group NPI through the provider Class screen and set up and individual through the NPI within the provider but have gotten rejections. Any suggestions?
Title: Re: Group or Individual NPI
Post by: Michele on October 08, 2009, 05:46:26 PM
Are the rejections from Medicare?  You need to call Medicare and verify the Group PTAN, NPI & EIN number to make sure their files match what you are billing.

Michele
Title: Re: Group or Individual NPI
Post by: tsbrown on October 20, 2009, 11:33:19 PM
Hi everyone. 

I just  received my Licensed Professional Counselor (LPC), Licensed Professional Christian Therapist (LPCT), and Certified Anger Management Specialist (CAMS) back to back.  I have a non-profit organization (working with homeless and working poor) which I've had since 1992.  I want a private practice and don't know if I should put it under my non-profit or make it profit.  The question is I don't know anything about medical billing and want to apply to become a provider for insurance companies.  I don't know if I should do it as a group or individual but I'm leaning toward putting the counseling center as a program under my nonprofit.  I don't have enough money to pay someone to bill for me yet, but does anyone have any suggestions about anything I've said.
Title: Re: Group or Individual NPI
Post by: Michele on October 21, 2009, 07:51:26 AM
Congratulations! 

As far as your questions, you need to decide if you want to bill under your ss#, or an EIN number for your private patients.  Also, are you going to have other counselors work for you in your private practice?  Many people form a corporation even if they are an individual for liability purposes.  I can't really advise you on whether to make it a program under your non profit company. 

Once you decide on these things you will need to contact the insurance carriers and ask them what you need to do to get on their network.  They will help you begin the credentialing process. 

Good luck!

Michele
Title: Re: Group or Individual NPI
Post by: PMRNC on October 21, 2009, 08:36:28 AM
Have to ask... WHY?  Many states have limitations on LPC's and many carriers also won't credential them. You are doing a great service I'm sure but do you want to have to completely change your thinking.. you won't be able to have the kind heart to discount patients anymore, non-profit and medical practice don't really go hand in hand, you'll have to completely change your way of practice :(  sounds harsh but Realistic!   Why not go to a private practice and be cash only provider, or maybe look into concierge care, so many options.. I wouldn't leap into the world of insurance without really looking at all the ramifications.  JMO   Give a discount or free care now and you are a wonderful person, give one later when you are in private practice accepting insurance companies and you could find yourself sanctioned or worse.
Title: Re: Group or Individual NPI
Post by: tsbrown on October 21, 2009, 03:17:13 PM
Thanks so much.  I'm not sure I understand your excellent answer because it was jam packed with mysteries for a newbie.  HELP!  I never even charged before during the 18 years of non-profit, but I have met my educational goals and need to bring money in now that I am licensed.  Please tell me what you mean by state limitations?  Carriers won't credential?  I will have to change my way of thinking completely?  So would you suggest LLC based on your experience (just asking your opinion)? What's concierge care????  Ramifications from using insurance?  Sounds like insurance for my profession isn't the greatest idea although I know a lot of centers use it.  I don't understand the pros and cons (that's a lot for this site I'm sorry can you suggest how I can research this).  Why would insurance sanction me for doing probono, it's encouraged in our profession by licensing board?  I'm sure when I have these answers I will understand why you're suggesting cash only.  Thanks so much.  Sorry I'm so ignorant right now.  Time heals all.   
Title: Re: Group or Individual NPI
Post by: PMRNC on October 21, 2009, 07:06:49 PM
Your not ignorant at all. Those are all questions you should be asking.
You have to research whether LPC's are recognized in your state, some states don't recognize them ..research "scope of licnese," and your state. As for the structure of your business, I suggest an accountant to advise you. Their are pro's and con's to Incorporating, LLC's, etc.

As for sanctions.. I'm sorry I should have explained. I have worked with various mental health providers who like you have done their fair share of pro-bono, charity and non-profit work. It's great for the soul but when it comes time to get into private practice what I have found is that most providers are not practical nor in the right frame of mind to get ready for the changes they have to make. For example, a patient presents with insurance coverage and either a $10, $20 copay or maybe 50% coinsurance and they don't have the money to pay their portion, it's actually "illegal" to routinely waive or discount the patient's cost-sharing with their carrier. With that said you have to be ready for the adjustment in the way you do business. Developing office policies, procedures, compliance manuals, etc all goes into this before you open your doors and even before you credential with the carriers you choose to credential with. When you begin accepting insurance the game changes .. completely.

My advice would be to find a good practice management consulting team to help set you up, get you educated, credentialed, get your office and policies done, HIPAA compliance, HITECH compliance..etc etc etc. 
Title: Re: Group or Individual NPI
Post by: tsbrown on October 24, 2009, 03:26:40 PM
Hi Everyone.

Alice and Michele this site is awesome, especially for a newbie.

Linda, I appreciate you so much.  GA does recognize and license LPC's.  I was licensed by GA Professional Licensing Board.  I did some reading and understand more what you mean about change my thinking.  In my new book, " The Paper Office," I saw things on balance billing like "if the MCO rejects your claim for payment..., your can only collect the copayment and not the rest", that's scary.  You're right, it is illegal not to charge the copay except I have an indigent clause clearly defining indigent and you should heavily document the clients indigence through investigation of the source of income or lack there of and not offer it, but let them ask.  I am still confused with your terminology of insurance companies credentialing us?  I don't know if insurances reimburse LPC's or if the organization has to be headed by a psychologist.  Linda, I have been reading about NPI's but am still a little confused.  I can apply for one individually using my ss# and that allows me to work anywhere and bill individually?  Or does that have to be associated with an address and business?  I have decided to do an LLC for profit but don't have start-up yet because rebounding from a son with cancer.  I have a choice to get a group number and attach it to my non-profit "group" since it already exists and switch it over in a few months when I can start the profit?  Can the group number switch from a nonprofit to a profit company or is it stationary?  I probably will not reach the amount of money for salary that will effect the non-profit in say three months anyway (it's been mostly inactive this year because of the cancer).  You can make a certain amount before you have to report or file taxes.  Or can I do the indigent counseling under the non-profit and keep the group NPI there, do an individual NPI for my for profit and also use the individual NPI if I do work with for other organizations?  Now, I feel like I am starting to know what kind of questions I really need to ask.  I am trying to read so I don't feel so lost.  I've always said I have a lot of degrees, but the more I learn the more ignorant I get because the more I realize I have to learn.  Thanks so much for your attention and help.
Title: Re: Group or Individual NPI
Post by: PMRNC on October 24, 2009, 03:53:47 PM
Wait until you decide on your structure of business, practice location, etc before applying for your NPI. Your NPI number must EXACTLY (right down to crossing t's and dotting i's) your Tax record. If there is ANY difference in the two files, claims will get rejected.

Some insurance companies have closed panels and some plain don't credential LPC's, you have to contact the ones you are interested in and they will tell you the credentialing procedure.

Your indigent policy is RIGHT on the money.. your office policy should clearly define indigence and then you document on case by case basis.
Title: Re: Group or Individual NPI
Post by: tsbrown on October 25, 2009, 12:26:48 AM
Thank You for This Site!!!  The Newbie. 

I am a preacher and I want to say I really feel blessed by God to have found this site.  Opening a new business is a serious undertaking and there's so many new things to know and do.  I find myself obsessed with reading it; things that effect me, things I don't understand "yet", and just hungry for the knowledge that is here.  People are real, personalities shine through and the openess and friendliness is astounding.  What it has done for me, a newbie, is pushed me to study and learn.  Because of this site I spent hours reading, "The Paper Office (especially a very revealing  look at games MCO's play in 'Ethical and Legal Issues in Working with Managed Care Organizations')," it's many internet references, other internet sites and this site.  Your site is thought provoking, challenging and jam packed with experts and/or people who are willing to share what they have.  It stirs my thirst for knowledge and drives me to learn more both on my own and from the site as a soon to be new business owner. 

Thanks Sooooooooooo Much.

P.S.  Especially you Linda for following through with me.
Title: Re: Group or Individual NPI
Post by: PMRNC on October 25, 2009, 02:19:05 PM
You are very welcome! Keep us updated! 
Title: Re: Group or Individual NPI
Post by: Michele on October 26, 2009, 07:03:31 AM
Just a side note, NPI's can be obtained in less than 30 minutes, so there is no reason to rush out and get one before you are sure what you are doing.  Linda is right, it is important to have all info on it the same as it is with the IRS.

Best Wishes!

Michele
Title: Re: Group or Individual NPI
Post by: PMRNC on October 26, 2009, 08:21:20 PM
Yeah that's VERY true.. actually I had one I setup last month that didn't take but 15 min and no problems <g>
If you have all your ducks in a row it makes it much smoother :)