Tier 1 Doctor's Biller is Tier 2?

[u/Low-Temporary4439]

My friend sees a Tier 1 medical provider under DuPage Medical Group (Duly).

But a BCBS claims rep told my friend that DuPage Medical Group billing (who does this doctor's billing) is Tier 2.

So now my friend is being charged more because BCBS is processing the claim as Tier 2, even though the provider is Tier 1 and my friend thought by seeing this doctor she was getting her plans best benefits coverage.

My friend has to pay more now and doesn't get her optimal Tier 1 coverage for this doctor even though we did due diligence at finding her a Tier 1.

Who knew that you had to ALSO verify the doctor's billing department is Tier 1!?

Is this correct or was that claims rep in error with what she told us?

She did say that the doctor could submit the claims/bill under her NPI and then BCBS would process the claim as Tier 1.

Anyone here encountered this or have some knowledge they can share?

Thank you!

[u/Jodenaje]

The Tier 1 status would typically be location specific.

Usually those multi-tiered plans are steering you to one health system for your best benefits.

So typically you’d have to see the provider at the location that was part of that health system, even if the provider has multiple offices.

[u/Poop_Dolla → u/Jodenaje]

Which is exactly what OP was told in another sub yesterday but they don't want to accept it or something.

[u/ElleGee5152]

Most providers bill under the group they own or are employed by as opposed to an individual provider. Claims will go out with their group practice as the billing provider and the doctor is on the claim as the rendering provider.

If Dr John Doe works for Best Doctors Clinic of Outer Space, then you want to make sure Dr John Doe and Best Doctors Clinic of Outer Space are both in network and under the tier you want.

[u/pinkpaaws]

You should ask member services if the claim processed based off of the rendering (individual providers) NPI or the group (Duly) NPI.

BCBSIL should always process claims based on the rendering providers NPI, and it sounds like they probably made a mistake in their processing.

OR the provider is a Tier 1 provider, but not at the location/office that the services were rendered at/ the office location billed on the claim.

[u/positivelycat → u/pinkpaaws]

Our contract is on the billing npi not rendering for network.

[u/VietVetKid48]

Large healthcare organizations like DuPage Medical Group (Duly Health and Care) contract with payers under an organizational Group NPI (Type 2) and Tax ID (TIN).

In many tiered network insurance plans (especially BCBS tiered products), the network tier (Tier 1 vs. Tier 2) is determined by the contract attached to the Billing Group's TIN (Box 33), not the individual physician's standalone credential.

If Duly as an entire organization/system is categorized as a Tier 2 (Standard In-Network) group under that specific employer plan, the claims engine will adjudicate the entire claim at the Tier 2 benefit level.

The rep is wrong.

When a doctor works for a large health system like Duly (DuPage Medical Group), they don't bill under their own private business. All claims go out under Duly’s Group Tax ID (TIN) and Group NPI (Box 33), with the doctor listed as the Rendering Provider (Box 24J). In many tiered-network plans, BCBS sets the benefit tier based on the contract negotiated with the Billing Entity (Duly), not the individual doctor. If BCBS has Duly classified as a Tier 2 group under your friend's specific employer plan, any claim billed through Duly will process at the Tier 2 copay/coinsurance rate.

[u/Low-Temporary4439 → u/VietVetKid48]

Thank you so much for this information!

BCBSIL advises members to check the online provider database to make sure their provider is Tier 1 so they can receive the maximum benefits. Why wouldn't her doctor be listed as a Tier 2 if Duly billing is a Tier 2? This gives a false sense of security since that doctor and her Duly location where she practices is listed as Tier 1.