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Radiologist Credentialing

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PMRNC:
The patient is ultimately responsible for making sure they visit only a provider in their network, however with Medicaid, often if they call ahead and they are traveling our out of state the state will issue a waiver authorization. I've seen this where a provider was par with their state Medicaid and Medicaid HMO but a patient comes in from out of state, when benefits are verified we find out the patient already contacted them and there was a temp authorization on file.. WHEN there is not, we try to obtain one and if not successful we tell the patient who is ultimately responsible and we have them sign a form similar to the ABN.  I've only seen this with a few states so i'm not sure if it's done all over or not, the patient will need to be forewarned it might not be covered.

Michele:
The problem is that most patients aren't even aware that the xray/etc is being read by a radiologist over the internet and that radiologist may be anywhere in the country.  We ran into this with the radiologist we billed for.  She gets an xray for an emergency, reads it, sends her report.  Then we bill the patient's insurance only to find that it is some obscure HMO that has no out of network benefits.  Pt gets billed and has no idea why.  No real way to forewarn.  Basically the provider has to deal with how they want to handle it.

PMRNC:
Yes that also happens a lot in the ER, patient goes in and there are 2 or sometimes more doctors, radiologists in and out and you don't have a clue who's in your network or not, the hospital could be in network but the physicians group isn't, this is ultimately a fight between the patient and their carrier. I have a pediatrician who runs into this all the time because he does work in the ER, he gets the referral and face sheet only, ultimately he's in the dark as well because there is no time to verify benefits, when this happens I have to bill the patient upon getting the insurance denial and explain to them they have to contact the insurance company and explain to them how to make the appeal.

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