Billing the Patient’s Plan or Billing the Local Affiliate: Difficulties for Home Infusion Providers Servicing Patients of National Corporations

A recent trend has emerged for home infusion providers seeking to service local patients who may be employed by, or receive healthcare coverage through, a large organization headquartered out of state.  When servicing the local patients, home infusion providers are often instructed to submit major medical claims through the local affiliate of the health insurer, despite the fact that the patient might have a plan issued through another affiliate of the insurer. This might occur, for example, in connection with Blue Cross Blue Shield plans, where, say, an Illinois-based home infusion provider servicing a local patient might be directed to submit claims to Blue Cross of Illinois (the local plan), despite the fact that the patient has coverage through, say, Horizon Blue Cross Blue Shield of New Jersey (since their employer is New Jersey-based). The local plan is then to reconcile and “true up” the claims with the patient’s plan.

However, this can create confusion and difficulties for providers processing and submitting claims. For example, the home infusion provider – despite being local to the patient and in-network with the local plan – is likely out-of-network with patient’s actual plan. This can create administrative and bureaucratic issues when seeking prior approvals or receiving payment on submitted claims. These situations can be further complicated if patients do not have out-of-network benefits.

Frier Levitt has assists infusion providers in navigating these bureaucratic issues and red tape, and in securing approval and payment for claims submitted. Frier Levitt can assist your company in developing practices and protocols aimed at addressing these issues in advance, and can help redress instances of claims denial or non-payment. If you’re experiencing similar issues, contact Frier Levitt today.

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