Wiki OON Pathologist

[mmsllc73]

Hello! Is it common practice to bill an OON pathologist under the provider who orders the biopsy? We are new to billing pathology and are being told that because our pathologist is OON, we can bill under the ordering provider. We did contract the pathologist with Medicare. I just want to make sure we are following the correct guidelines. When I call the different commercial plans, the reps give me the runaround, which is so frustrating. There is no provider relation to help anymore with questions like this! Also, do most payers allow pathologists to be enrolled in their plans? I would appreciate any feedback you can give me. Thank you in advance.

 

[xXxPARAGONxXx]

Hello! Is it common practice to bill an OON pathologist under the provider who orders the biopsy? We are new to billing pathology and are being told that because our pathologist is OON, we can bill under the ordering provider. We did contract the pathologist with Medicare. I just want to make sure we are following the correct guidelines. When I call the different commercial plans, the reps give me the runaround, which is so frustrating. There is no provider relation to help anymore with questions like this! Also, do most payers allow pathologists to be enrolled in their plans? I would appreciate any feedback you can give me. Thank you in advance.

My Blue Cross Blue Shield has the following in the 2024 service benefit plan brochure:

Under Basic Option, you must use Preferred providers in order to receive benefits, except under the situations listed below...

3. Laboratory and pathology services, X-rays, and diagnostic tests billed by Non-preferred laboratories, radiologists, and outpatient facilities;

In other words, if your pathologist is OON, and you submitted a claim to my insurance for pathology services, my insurance would pay the pathologist as though the pathologist was in-network (i.e., a preferred provider). No need to worry about billing under the ordering provider.

Why not look up the service plan brochure for the subscriber's insurance?

 

[mmsllc73]

My Blue Cross Blue Shield has the following in the 2024 service benefit plan brochure:



In other words, if your pathologist is OON, and you submitted a claim to my insurance for pathology services, my insurance would pay the pathologist as though the pathologist was in-network (i.e., a preferred provider). No need to worry about billing under the ordering provider.

Why not look up the service plan brochure for the subscriber's insurance?

Thank you, this is great information. I will look into the service plan brochure for the insurance.