Wiki Non-Par Providers

[lucretiab]

I have a non-par provider who had a biller who was submitting her claims as par and non-par I guess depending on her mood. This has created a huge problem for the provider that I am now billing for. This is a bigger mess that I was initially lead to believe. What I want to know is if I should do a complete audit of her other patients as well to make sure that this didn't happen for all her patients. Also if we need to refund Medicare and rebill these claims because she billed her patients and they reimbursed her up front. Help please in cleaning this situation up! This is an absolute mess!:confused

 

[pamsbill]

You need to specifically list the issues you have uncovered. It is difficult to give advice on generalities. What did she do with the Medicare patients? Did the physician receive any Medicare payments? Did the patients receive any Medicare payments? A non-par Medicare provider must submit using the limiting charges published by Medicare. Was she using those when she sent in the Medicare claims and when she billed the patients? If she submitted non-par BCBS claims, they probably paid the patients, in which case you would just bill the patients. I think you want to start with Medicare and get that straightened out first, since they have severe penalties for not abiding by their rules.