4. Is there any risk to my primary practice of having reduced rates on reimbursement based on my new type 2 NPI
To add to this question, we started a new practice and are contracted with some insurance companies. Some of our providers (all W-2 employees) have their own practice and their own NPI number. With one insuance company, I wont give the name, doesnt pay us per our contract. They pay (1) per the patients contract with them or (2) per the contract that our w-2 provider has or doesnt have with this insurance company. Our claims are correct with the appropriate information when submitted.
Example: Our contract payment = 225% of the Medicare allowable.
Dr. Jones is W-2 employee. He is non par
Dr. Smith is W-2 employee. He is par being paid 80% of Medicare.
Claim for Bert N Ernie sent to carrier. Dr. Jones treated patient. Claim payment sent to patient. Calls to carrier says we are non par group.
Claim for Blondie N. Dagwood sent to carrier. Dr. Smith treated patient. Claim paid at 80% of Medicare. Calls to carrier says our contract to be paid at 80% of Medicare. When Dr. Smith treats his own patients in his own practice, this same carrier pays his claims at 225% of Medicare. Sounds nice, but he faces constant refund demands and offsetting of his claims payment.
The problem we face is not universal with every insurance company. Just with this one insurance company. We've terminated the contract several times. Each time they put pressure on the provide to recontract. We just teminated again and we are now in court to resolve this. The Hospital CEO terminated the contract we had and revoked all privileges until recontracted. This too is now in the court system for resolution. This may not be an issue you will face but serves as an example that even when you do things right, something can go wrong. We did have some minor hiccups with other insurance companies, such as incorrect payment amounts, checks sent to the wrong address, but after making calls, they were fixed.