Author Topic: IN NETWORK PROVIDER/OUT OF NETWORK FACILITY  (Read 1105 times)

jrnmthc

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IN NETWORK PROVIDER/OUT OF NETWORK FACILITY
« on: February 04, 2016, 12:49:22 PM »
Hi if new rendering provider who is in network joins out of network facility (npi and tax id), how will the bills be paid in network or out of network?  Thank you!!

RichardP

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Re: IN NETWORK PROVIDER/OUT OF NETWORK FACILITY
« Reply #1 on: February 05, 2016, 12:22:49 AM »
The in-network or out-of-network distinction is always tied to who gets paid.  And who gets paid is always the billing entity.

So - in your situation - who is the billing entity?  Whose NPI Number is being submitted to the Insurance Carriers in Box 33a of the CMS 1500 form?

Since your provider joined something, I assume that the facility is the billing entity, with its own NPI Number and EIN.  I assume that the facility bills, with its own NPI Number, the insurance carriers pay the facility, and the facility pays the provider for the work s/he does.

If your provider is the billing entity, and his NPI Number is placed into Box 33a of the CMS 1500 form, then the insurance carriers will be paying your provider according to whatever participating provider agreement is in effect.

jrnmthc

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Re: IN NETWORK PROVIDER/OUT OF NETWORK FACILITY
« Reply #2 on: February 05, 2016, 09:02:01 AM »
yes that is exactly what I assumed.  The facility would be paid because they are in Box 33.  Thank you so much!!

jrnmthc

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Re: IN NETWORK PROVIDER/OUT OF NETWORK FACILITY
« Reply #3 on: February 05, 2016, 09:04:24 AM »
However, my boss still asking me, will we get paid in network rate or out of network rate if the facility NPI has always been on file with the insurance as out of network. Because all previous providers were out of network, but now this new doc is in network.  Can he remain in network and will he be paid in network rate or out of network?  Any idea?

RichardP

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Re: IN NETWORK PROVIDER/OUT OF NETWORK FACILITY
« Reply #4 on: February 05, 2016, 03:05:51 PM »
If the facility is the billing entity, then your boss is not being paid by the insurance carriers.  The facility is.  Insurance payment will be made according to the contractual agreement between the facility and the individual carrier.  How and what your boss will be paid is determined by whatever agreement he has with the facility.

Keep in mind that a provider can be employed by multiple facilities at the same time (obviously working part-time at each).  The insurance payment agreement is between the carrier each individual facility.  What that agreement might be is irrelevant to the provider.  His pay is determined by his agreement with the facility, not the insurance carriers.