Understanding Provider Definitions

Management and Administration
1

aethelwulffe wrote on Wednesday, December 15, 2010:

I am in the process of setting up a system for an operation that deviates from the medical clinic norm.  It is a mental health agency (501c) that uses contract-paid counselors with varying levels of licensing.  Some advice from someone else dealing with contracting providers (especially Mental Health) would be especially helpful, but i am gonna bug all of you for help.
 
Here is the organization:

Group NPI
    |
Billing (Rendering) Providers= Counseling Supervisors
        |
Contract Counselors

Counselors are paid a rate per-unit/by-procedure for what work they do, not a salary or hourly wage.  They have an NPI.
Supervisors get a percentage of the take of their counselors, as they have to monitor the cases etc…  Their NPI is used as the Rendering Provider

Looking at the following fee sheet, we have three levels of providers listed here:

Provider, Rendering Provider, and Supervising Provider

If I understand correctly, Rendering Provider is the most important, as that NPI gets paid.  Supervising Provider is optional.
  Currently, in the above example, “Clinician,RMHCI,Test” is the contracting counselor.  “Eaton,LMHC, Linda” is the Rendering Provider, and I am not really sure what the heck Supervising Provider (filled in here with “Administrator” for show) is even for.

Problem #1:  I need to understand more about who should be listed as which provider in our >particular< context.

Problem #2:     I (and other clinics like this one) must track the “Eat what you Kill” data for each provider listed.  I think I can currently only get a billing report listed by rendering provider (The Counseling Supervisor), not by the clinician that actually did the therapy session.  I need billing data broken down both ways so they can pay both levels of provider.

Problem #3   If I am correct, and current reporting will not give me payment/billing totals for the Counselor level providers, I will either need an SQL query that is pretty slick, or a customized report.  I think at a bare minimum, I will want to be able to search a date range for procedure codes by Counselor (Clinician,Test), and the number of units of that procedure code.  More data, like whether or not it has been paid, who/what encounter/date it was for and all that would be VERY nice.  What route should I take on this?

2

aethelwulffe wrote on Wednesday, January 05, 2011:

Just bumping this bit here.

    I’m still trying to understand all this.  I would really like to document/illustrate this whole issue for a manual submission, but I am afraid I am far from understanding the way different things integrate to spit out billing properly.  When entering claims directly on-line, we use our counselors numbers, but that does not seem to work for an 837 (as yet).

I have an additional question related to one that John (“biller”) brought up, though I still have no answer for any of my above questions:    When setting up insurance numbers, you have an option for Provider number, and for Rendering Provider number.  If “Test Clinician” has a Medicaid number, but is not actually a “Rendering Provider” for your group’s billing, is the “Rendering Provider” insurance number their clinical supervisor’s number, or something different?  Our EDI help folks really are lost with these questions.  I suppose I should just map out the x12 gen file to determine where everything comes from, and modify the titles of the input fields to reflect the loop and segment they go to, but without understanding the provider definitions properly, I think I will still be hosed.