How do I work out with par and nonpar clms submission with insurance plans.

[Michele]

Question

Hi Michele,
my question: How to work out with par and nonpar clms submission with plans. Our group has 2 providers. One par and the other non-par but the "Group name" is par. Clms are sent in as non-par when pts plan had out of network benefits and after pt agrees (we work with ded, etc.). Carriers explain how we are contracted and tax ID is how clms are processed and the driven factor for reimbursement. The question is how to divide this Practice? Is a completely separate Tax ID or to opt out for both providers? On what basis can we base a decision to opt out completely vs. obtaining another TAX ID? We have been provider for over 18 yrs. Our referral mainly come from health care providers, very few from our newspaper ad. Not many from the insurance provider directory because we notice each secretary having a list of provider they refer to. Can you give me your input. Thank you.
Naomi

Answer
Hi Naomi,

Your situation is a tough one. If the insurance companies use the tax ID# to determine if you are par, then there is no way to bill one provider par, and one non-par. If they went by the provider's name, then you could bill under the individual's name instead of the group name, but by what you explained, they do not. We do have one provider that participates with an insurance company, but the company only has the dr as par, not the group name. If we bill with the group name then they process the claim as out of network. However, in your situation, it sounds like you need to either have both providers in network, or both out of network. The only other thing I can suggest is to contact the provider rep for that insurance carrier to see if there is something you can do.
Hope that helps.
Michele

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