Credentailing - Closed Network

casseciella

Networker
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Huntsville
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Can anyone give advice on how to appeal/overturn a payer having a closed network?

I work for a laboratory, and it seems almost impossible for payers to accept us because they always say the network is closed; "their existing network is comprehensive to meet the needs of our customer", is generally the denial I get. Any suggestions on what we can do overturn this?

Thanks!
 

danachock

Guru
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Brainerd, MN
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Hi casseciella,
Have you personally called yourself on these denials? Having a coder versus an AR representative will seriously cut down on figuring out your denials. I do not have any remittance or EOB adjustment codes to review ...... If you NRP'd patients because "their network is closed" that somehow network is "comprehensive to meets the needs of their customers" and you start billing them ..... what happens aside from plenty of PI (patient inquiries). I do not know if the facility needs to eat this or if we can NRP the patient. Did you check, do we have an ABN? If the laboratory doesn't meet medical necessity because "it NEVER DOES" did you apply the necessary GY modifier??
I would be happy to help, I simply need a little more info please.
Thanks for listening,
Dana Chock, RHIT, CPC, CANPC, CHONC, CPMA, CPB
 

casseciella

Networker
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Huntsville
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Hi Dana,
Thank you for your response, however I wasn't referring to denials on EOBs/Remits. I am referring to not being accepted into a payer network as a PAR provider. The reason that we always seem to get is "their existing network is comprehensive to meet the needs of our customer." So I was wondering if anyone had advice on what we could do to become PAR providers?
 
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CodingKing

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Many payers have exclusivity agreements w/ labs so there is no way around that. If you provide some special covered lab test that is not available through the participating lab, that is one way to get in to a carrier with a closed panel
 

casseciella

Networker
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Huntsville
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Many payers have exclusivity agreements w/ labs so there is no way around that. If you provide some special covered lab test that is not available through the participating lab, that is one way to get in to a carrier with a closed panel
Thank you! We have appealed to explained how our testing is different, but I guess it is not different enough. So I was just trying to see if there was any other option. Thank you!
 
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