Article 16/28 Clinic billing question

We are an Article 16 / Article 28 outpatient clinic facility entitled to an enhanced Medicaid rate for our developmentally disabled population. We do not par with any payers, and that entitles us to cross over to Medicaid for the enhanced APG rate.

The problem we are experiencing is that some payers, will process our claims in-network based on the rendering provider's NPI, if that provider pars with them in his private practice. This results in a reduced reimbursement as we will only be reimbursed by Medicaid for the allowed amount. This is happening even though we are billing under our facility tax ID which is not in network.

Specifically Oxford and BCBS have been the most problematic. We were able to resolve the Oxford claims by submitting Institutional claims rather than Professional. However BCBS refuses to recognize our facility claims because we are registered with Medicare as a part B provider and don't have the credentials to bill as a facility.

If anyone is familiar with this scenario, your input would be greatly appreciated.

re: Article 16/28 Clinic billing question

I am curious to see one of your denials or what CPT® codes you are trying to get paid as a Facility claim.

re: Article 16/28 Clinic billing question

It is not an issue of denials, the issue is that BCBS refuses to process our facility claims because we are not registered with medicare as a facility. Our professional claims were processing as in network, based on the rendering providers NPI if he was in network in private practice. This reduced our reimbusement on medicaid crossovers to the lower allowed amount.

Today, we have been advised by a BCBS onshore supervisor, to list the clinic's NPI in Box 24F instead of the rendering provider's NPI. This would cause claims to process as out of network, and allow us to cross over to medicaid for the full reimbursement.

Is anyone aware if this is accepted billing practice?