Tax ID for Drs Office Conundrum!

[10452km2]

Hello,

This question relates to how insurance companies deal with Dr office's Tax IDs.

A Dr's office has a Tax ID they use to submit claims to an insurance company (i.e:Aetna). Lets say the Tax Id is (123456789). This Drs office has always used this tax id to submit their patients claims and the insurance company always viewed them as (in-network) for all these years. For some weird reason insurance is alledging that the drs office is sending claims under an (out of network) tax ID (12345789). But the doctors office says for all these years they have been using that same TAX ID (123456789) which is always( in network ) and insurance has always processed these claims as (in network.)

A couple months ago patients started getting billed for seeing this Dr as an out of network Dr. The insurance is alledging that this Tax id (which the dr has used for many many years - is now out of network) . Insurance claims they have another tax id on file, lets call it tax id# (34343434) which is an in network tax Id which is the one the dr SHOULD be using. The problem is the Drs office has no affiliation with this tax id and doesnt understand where it came from. 

So the question is:

1.) how come all of a sudden now the insurance is saying their Tax id (123456789) is out of network, while a few months ago this tax id was used to process claims and was viewed as In network. What went wrong?

Insurance was ALWAYS processing claims under the tax is (123456789) as in network. How is it possible that now that tax Id is deemed invalid when the whole time the insurance WAS processing claims as in network and stopped doing this a few months ago and now deems the tax id as out of network?

Thanks

[Kerry]

My first thoughts are that it is possible the insurance company made an input error on there end.  I have experienced this before and it was not fun trying to get them to fix their mistake.  The insurance company could not tell me where they got the incorrect tax ID.  Unacceptable in my view.  But, I held them to it and got it corrected.  It took many phone calls!  Be sure to ALWAYS document each and every call.

My second thoughts are maybe the provider did not recredential during the recredentialing period.  Therefore, provider dropped as an in network provider.  Communication very important between provider and billing person. 

The patient should not have been billed because of this problem.  It is not the responsibility of the patient to pay out of network fees when in fact the provider is in network.

I would suggest calling the insurance company that you are having this problem with and talk to provider relations to find out status of the provider.  Are you having problems with all insurance companies you submit claims to or just one?

Hope this will help.

[10452km2]

When is the recredentialing period during the year? Do drs offices usually recredential in January? What is this process like?

I think its unlikely there is any error with the Tax Id being documented "improperly" because thats the only legitimate tax Id the drs office has used in their entire existence since years and years.

If they did not recredential themselves that doesnt explain why prior claims were accepted under the same tax id as in network. How can the tax id be accepted in the past as in network but now it is out of network. It doesnt make sense. Even if they did not recredential which i highly doubt the insurance should not say "you are not in our system"

[Kerry]

It depends on the insurance company as far as recredentialing.  It's not every year. 

I am not saying Tax ID documented improperly on your end at all.  What I am saying is that it is possible that the insurance company made an error and used another provider's Tax ID.  I am just trying to give you some ideas as to what might have happened.

I would contact the insurance company you are having a problem with and ask to talk to a Claims Supervisor and ask questions as to why this is going on.  Good luck!

[Michele]

I agree with Kerry.  It sounds like the provider may not have been re-credentialed.  I've seen this a few times.  They say they sent out a request for re-credentialing, but the provider doesn't seem to have received it.  I've seen it in particular with Aetna.  We had a provider in network for several years then suddenly everything was being processed as out of network.  When we called we were told that they terminated her contract because she didn't respond to re-validation requests.

Also, the insurance carriers sometimes add plans but providers who are in network with them are not automatically in network with the new plans.  The provider has to request to be put in network.  SO it could be either of these.  In either case you need to contact the insurance carrier to find out.