Wiki Billing with Group vs. Individual

[medicalbillingjh]

One of my new physicians would like to start his own practice and wants to back bill for cases he performed in hospitals(the group doesn't have a problem with this). The issue I see is that he is/was with a group and is In-Network under that group. Would I be able to bill for his cases with his individual NPI as Out of Network?

 

[thomas7331]

It is common for providers to work with multiple practices or groups, and they may be in-network with one group but out-of-network with another. He would need to establish his own practice with a separate tax ID number, enroll with payers as needed and operate that practice as a separate entity, even though in both practices he will use the same individual NPI number as the servicing provider.

You can certainly bill this way, but it could end up being very problematic for patients, though, especially if he is seeing them in the hospital under a different group and network affiliation - they may not understand that they are receiving out-of-network services from him in the hospital if they have seen him in the office and in that setting the services we in-network. This could generate complaints and payment problems with the insurance companies. I'm not sure I understand why he would want go to trouble of doing this instead of just billing the cases through his current group?

 

[SharonCollachi]

In California, if the hospital is in-network, all services by providers performed in that hospital are treated as if they are in-network. State law to avoid surprise bills. His reimbursement will, therefore, be exactly the same.

Why haven't the cases already been billed by the group? If they have, it would serve no purpose to try to change that now.