NPI issue with ALF billings

[kristin]

Wondering if anyone else has come across this issue, and if so, did they find a solution? I work for a billing company remotely that has 2 podiatrist clients in a group practice in PA who go to various ALF's, I have been doing their billing since 2013. Some of the ALF's have NPI's, others don't, and the ones that don't CAN'T get NPI's, because they do not qualify for them, as they do not provide any type of medical care.

For the ALF's that do not have NPI's, we have always billed the claims with the ALF's name and address in box 32, with the group NPI for the podiatry practice in box 32b, as an NPI is required in box 32b by both insurance companies.

Starting at the end of last year, one particular insurance company, IBC (Independence Blue Cross) started denying all the claims for the facilities without NPI's, stating the NPI did not match the name of the facility. We reached out to our provider rep about this, and we were told all we could do was to submit appeals through Navinet on each claim. Which we did, and although it takes two rounds of appeals per claim, the claims do eventually pay. This issue is that each claim takes about 10 minutes to appeal through Navinet, times 2, since it takes 2 rounds of appeals to be paid. So 20 minutes per claim over the course of a few weeks, and there are usually 10-15 claims to appeal every few weeks.

Additionally, starting this year, Cigna Healthspring is rejecting all claims from these same ALF's at the clearinghouse level, stating the NPI does not match the facility name. So we can't even get the claims to go through, at all. And I know if we could, they would then deny once they got to Cigna Healthspring for NPI not matching ALF name.

Does anyone have any suggestions on how to handle/correct this situation? We have spoken to provider reps and CSR's repeatedly, and they can offer no help other than saying to appeal claims and to have these ALF's get NPI's. (Which they cannot do as they don't qualify, and if they could, I sincerely doubt they would bother to do so. They can barely get us accurate demographic information on a good day for their residents.)

Thanks,
Kristin

[Michele]

We have not submitted for DPMs in ALFs but we have submitted for MH providers in ALFs.  We always use POS 13 and put the facility's name & address in box 32 but left 32a blank because it was the same as seeing patient's in their homes, which 32a is also left blank.  It sounds like a couple of insurance carriers are now starting to have an issue with this.  It seems crazy to have to appeal each claim.  I'm not sure if the ALFs would be open to it, but they can actually get an NPI even if they do not provide medical care.  They may have to select a taxonomy code that doesn't require licensing but they can get one.  The app is pretty easy, maybe if you offer to complete the app for them?  You would have the number within minutes.  Problem solved (hopefully!).

[kristin]

Thank you, Michele! I will let every know that the facilities CAN get NPI's, that is great news!