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ruthie72:
well I am doing the best I can on educating my provider..but she says she is going to charge them whatever the other establisment used to charge them and for me to wait to bill until she is In network...I just hope this works..the only problem is..she does not understand that she is seeing these patients now and she is NOT IN network..when I bill the dates the insurance companies are going to know that she is not in network correct??? Then she will either owe the patient or lose out on money she could have had? Am I right? or am I crazy? I am so confused right now.

RichardP:
I know that when you apply to be a Medicare provider, there is a certain point in the process where you become eligible to bill Medicare, even tho you are not set up completely in their system at that point.  Medicare's counsel is to hold off on billing at that point until they are ready to accept the bills.  When they give the signal, you can submit bills for service back to your eligiblity date.  I don't know if such a situation exists with any of the private carriers in your state.  You could check.

Bottom line is, your doctor won't get paid from Insurance Carriers for services she provides before she becomes a provider unless the Carrier gives her permission.

ruthie72:
Thank you Richard..so basically I am right? If she saw a patient on 02/28 and does not become IN network until 03/15..when I submit the claim and the DOS is 02/28, will she still get paid as an OON provider? I just want to be able to explain this to her when it happens without getting things in an uproar...she is a little stubborn..lol ;D

PMRNC:


--- Quote ---Thank you Richard..so basically I am right? If she saw a patient on 02/28 and does not become IN network until 03/15..when I submit the claim and the DOS is 02/28, will she still get paid as an OON provider? I just want to be able to explain this to her when it happens without getting things in an uproar...she is a little stubborn..lol ;D
--- End quote ---


That's correct. She will get the OON rate.  With OON it's not "allowable" but rather Usual & Customary meaning if the carrier cuts the charge $50 for example, that $50 is patient responsibility. When the provider has officially become IN Network (Contract will have start date) then there is an "allowable" fee schedule to which you adjust off the difference between the allowable and the billed charge. For example if the charge is $75 and you are now in network, carrier ALLOWS $70, that $5 is your participating adjustment but you can bill the patient the diff between the Paid and the allowable, that is their OOP Coinsurance/copay/deductible

RichardP:
What Linda said.

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