Case Study: Resolving Ophthalmology NPI/TIN Mismatches to Prevent Out-of-Network Losses
A New York ophthalmology practice with 2 providers faced unexpected disruptions in reimbursement due to hidden credentialing and billing setup issues. What began as routine claim submissions quickly escalated into a major financial setback—impacting network status, payments, and overall cash flow
With losses mounting, MBW RCM stepped in to uncover the root cause and guide the practice toward recovery. Read the full case study below to discover what went wrong—and how $825,847 in revenue was brought back on track.
Customer Situation
The practice had no standardized documentation to guide staff on credentialing rules, payer-specific requirements, or how to choose the correct NPI/TIN for each scenario. Without a clear reference, team members relied on assumptions, often selecting the wrong billing entity or network classification.
Because of this lack of clarity, BCBS claims were routinely submitted under incorrect NPI/TIN combinations. The repercussions were significant:
All BCBS HMO claims were denied outright
BCBS PPO claims were paid at reduced out-of-network rates
Payments were routed to outdated or incorrect pay-to addresses
AR increased dramatically as staff attempted to correct and appeal recurring denials
Every incorrect submission added to the financial burden. The practice struggled to keep up with rising denials, mounting AR, and dwindling cash flow, creating a cycle of operational frustration and uncertainty.
Challenges
MBW RCM’s audit revealed several critical issues that contributed to the revenue loss.
Credentialing & Submission Mismatch
Although BCBS credentialed the provider under the Group NPI/TIN, Nextech and Trizetto were submitting claims under the Individual NPI, causing BCBS to categorize them as out-of-network.
Lack of Internal Documentation
No written guidelines existed for billing rules, entity selection, or network usage. Staff were unaware of which provider preferences applied to which services, leading to inconsistent claim submission patterns.
Incorrect PM & EDI Configuration
The system configurations contained outdated or incorrect:
Network indicators
Taxonomy codes
NPI/TIN mappings
Pay-to addresses
These systemic errors meant that even corrected claims were resubmitted incorrectly, perpetuating the problem.
Revenue Leakage and Delays
Correcting credentialing mismatches with BCBS and updating EDI enrollment required 3 months. During this time, the practice continued to experience denials and underpayments, worsening AR aging and delaying cash flow even further.
Solution
MBW RCM approached the issue with a comprehensive remediation plan. They began with a full credentialing, PM, and EDI audit to uncover all discrepancies between BCBS enrollment records and the practice’s system configuration.
Once identified, MBW RCM:
Corrected all NPI/TIN mappings to match BCBS credentialing
Updated network indicators and billing entity assignments
Validated taxonomy codes and pay-to details
Reconfigured Trizetto EDI enrollment for clean, accurate claims
Ensured Nextech mapping reflected the correct group enrollment
Before resubmitting any claims, MBW RCM performed a complete validation to ensure accuracy.
To prevent future issues, they created clear internal documentation outlining:
When to bill under Group vs. Individual NPI
Provider-specific in-network and out-of-network rules
How to submit surgical services requiring different billing status
Steps for verifying credentialing combinations before submission
Claims were placed on temporary hold until BCBS confirmed and activated the corrected setup, preventing additional losses while changes were pending.
Results
Once credentialing and system corrections went live, claims began processing cleanly. MBW RCM systematically resubmitted every affected BCBS claim, allowing the practice to recover $825,847 in previously denied or underpaid revenue.
The outcomes included:
Accurate network billing, eliminating NPI/TIN mismatch denials
Higher clean-claim rates, reducing work for staff
Faster, predictable reimbursement, improving cash flow
Clear workflows and documentation, reducing provider and staff confusion
Long-term stability, preventing future credentialing-related revenue loss
What began as a costly credentialing and billing crisis ultimately became a turning point. With expert intervention, accurate system setup, and standardized guidance, the practice regained confidence in its billing operations and secured a more reliable revenue cycle.
Schedule a consultation
NPI/TIN mismatches and provider setup errors can lead to out-of-network payments and unnecessary revenue loss. MBW RCM helps ophthalmology practices correct credentialing and billing configurations to prevent denials and improve reimbursement.
To learn how we can help your practice eliminate network-related issues and strengthen financial performance, fill out the form below — our team will contact you soon.
