I got a $15 bill recently after already paying my $25 copay for a visit with my PCP. When I called Anthem, they said it was because I saw a Nurse Practitioner instead of a doctor, which made it count as a specialist visit with a $40 copay.
I live in MA, and NPs can be listed as primary care providers here (mine is). So I don’t get why the copay is different from what’s on my benefits statement, which clearly says $25 for PCP visits.
I called my PCP’s office and they said they’d check the billing code but didn’t promise anything. I also emailed Anthem with proof showing my NP is my PCP, along with a copy of the bill, my benefits, and even info about the policy change in MA allowing NPs to be PCPs.
Any advice on how to get Anthem to fix this? It doesn’t make sense that choosing an NP over a doctor, which should save them money, ends up costing me more. I could switch to an MD, but I like my NP and it’s tough to get an appointment with an MD at nearby hospitals.
Sounds like Anthem doesn’t have your NP listed as your PCP. Sometimes you have to call the insurance directly to update it, even if your NP is marked as PCP at the doctor’s office. Their records don’t always sync.
I’d double-check that Anthem even allows NPs to be PCPs. Just because it’s legal doesn’t mean the insurance has to follow that. I used to work at a place where Blue Cross was a headache about credentialing NPs.
I had something similar happen – turns out my primary care doctor was also listed as a geriatric specialist without me knowing. Cigna billed it as a specialist visit. Took forever to get it sorted.
Nurse Practitioners and Physician Assistants can sometimes get billed as specialists if they work in a specialist’s office. If the claim didn’t clearly say ‘PCP,’ they default to the higher copay.
Sometimes, the fix is simple – ask the office to resubmit the claim under the PCP’s name or list the supervising doctor. It can get adjusted that way. Long-term, the office needs to update how their NPs and PAs are registered with insurance so this doesn’t keep happening.
@Jesse
Yeah, I’ve seen that happen. Insurance usually processes claims based on the provider’s specialty code. If the NP used to work in cardiology and didn’t update their credentials when they switched to family practice, the insurance still treats them as a cardiologist.
@Jesse
That’s a good point. NPs can specialize and get certifications, so they might get billed differently. Some states let NPs practice independently without a supervising doctor, which can mess up how insurance codes the visit.