Author Topic: Network Participation  (Read 1009 times)

ste

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Network Participation
« on: April 28, 2014, 06:48:37 PM »
Does anyone have any stories they might like to share about adding a provider to a panel that was supposed to be closed?

kristin

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Re: Network Participation
« Reply #1 on: April 28, 2014, 07:04:29 PM »
I don't have a story to share, because that has never happened to any of my providers, but I did find this article that may be helpful:

https://www.hfma.org/Content.aspx?id=881

PMRNC

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Re: Network Participation
« Reply #2 on: April 29, 2014, 09:13:45 AM »
I have encountered this before. Twice actually. Once was a psychologist in NJ who I was able to get into a closed network (BCBS) because he specialized in EMDR.. another was a psychiatrist out here in upstate NY where we have shortage of psychiatrists.
Sometimes you can get a provider into a closed network for a couple of different reasons.. one might be lack of that same provider type within a certain area. Carriers usually have their own criteria for example, out here we have ONE dermatologist within 150 mile radius. Another reason might be a type of service that provider does that other providers of same type do not do as was my case with EMDR.  There does have to be a good reason for them to credential into a closed panel. You actually would do an appeal the same way you would do one with a claim. You assess the services and the area, determine if there is a special need for that provider or a special service they provide that is not common in the area, and then you appeal to the carrier with your documentation/research.
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Michele

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Re: Network Participation
« Reply #3 on: May 01, 2014, 11:08:13 AM »
I have the same experience Linda has.  Usually there are three reasons they will allow a provider into a closed panel.

1.  The provider offers a service that is unusual/different than other in network providers.  An example is if an LCSW specializes in interactive play therapy for younger children, or uses a service animal to aid in their work.

2.  They are joining a group that is already in network with said insurance carrier.

3.  The provider is replacing an in network provider who is moving or retiring, or for some other reason leaving practice in the area.
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