Medical Billing Forum

General Category => General Questions => Topic started by: ste on January 22, 2018, 01:57:28 AM

Title: Networks
Post by: ste on January 22, 2018, 01:57:28 AM
Can a Practitioner be non-par with a home plan while being PPO with the host plan?
Apparently so. A Bluecard rep who had sent a claim back for reprocessing because it had processed out of network called me today and said the claim processed correctly. Each home plan has unique and specific criteria to determine the network status.
When I verified benefits and asked if the practitioner was in network with the patient’s plan I was given the usual response, “Is she PPO with your local?” Yes. Then she is in network with the patient’s plan.
The patient has had same insurance and sees the same practitioner whose credentials have not changed. I have billed her insurance for 8 years without issue until now.
Title: Re: Networks
Post by: Michele on January 22, 2018, 10:20:14 AM
My understanding is that if a provider is par with the local then they are supposed to be par with all plans.  If you have been billing the patient's insurance all along without issue then most likely it is a processing error.  Do you have a local provider rep who can look into it further for you?  I would give an example of the most recent one that paid and the one that denied.  Or call back and get a different rep to look into it.  Just seems wrong.
Title: Re: Networks
Post by: ste on January 23, 2018, 07:05:31 PM
Linda answered this question or a similar question in the past but I couldn’t quite grasp the concept. This patient has a med-advantage plan, so unless the provider is a Medicare Provider claims are going to process out-of-network. But this begs the question, if Medicare does not recognize the specialty, in this case acupuncture, then how can the patient see an in network provider? The answer is the patient needs to see an MD who is a Medicare Provider and also has a DO or LAc credential allowing him or her to perform acupuncture.
I knew I’d get it eventually. 
Title: Re: Networks
Post by: PMRNC on January 25, 2018, 06:43:55 AM
Ahh.. see from original post I didn't realize this was a Medicare Advantage plan, that does change things. If the provider is not an "eligible" provider that does change things. I'm really rusty on Medicare and advantage plans now.  ::)