Wiki Denials for New Patient visits When Prior PFT/Sleep study Interp has been completed

tothks

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I have in the past been denied a new patient visit with BCBSM for billing a new patient visit after the reading of a PFT done at the hospital. I appealed it and they paid it. But now Priority Health is doing the same thing. This is not right and should not be allowed for an established patient billing. The work that goes into a new patient visit needs to be defended by us as Coders/Billers. There is no way they can bundle or whatever they are doing to say this is okay for the insurance companies to take this revenue from our providers. Our providers that provide the service of interpretation of these studies need to be compensated appropriately they have no idea they will get a consult out of the interpretation of those tests they read. The patient I am currently appealing had simple spirometry 94010 read at the hospital and was consulted for a sleep study. This is not right in any way shape or form and in my opinion needs to be fought and the more that fight the better the chance of this practice being taken away from the insurance company. Has anyone else appealed the insurance for proper payment of the new patient visit?
 
I have in the past been denied a new patient visit with BCBSM for billing a new patient visit after the reading of a PFT done at the hospital. I appealed it and they paid it. But now Priority Health is doing the same thing. This is not right and should not be allowed for an established patient billing. The work that goes into a new patient visit needs to be defended by us as Coders/Billers. There is no way they can bundle or whatever they are doing to say this is okay for the insurance companies to take this revenue from our providers. Our providers that provide the service of interpretation of these studies need to be compensated appropriately they have no idea they will get a consult out of the interpretation of those tests they read. The patient I am currently appealing had simple spirometry 94010 read at the hospital and was consulted for a sleep study. This is not right in any way shape or form and in my opinion needs to be fought and the more that fight the better the chance of this practice being taken away from the insurance company. Has anyone else appealed the insurance for proper payment of the new patient visit?
It happens, most insurance companies using auto adjudication will automatically deny a New patient visit, when that same provider/group has billed under that same NPI/TIN in the past 3yrs. You are correct that "professional services" only, are not a component for determining Est vs New visits, It should only take a simple appeal or phone call to get this corrected. In my personal experience, I see many more providers billing New pt visits that actually should be Established due to history (group/specialty/sub-specialty), than the other way around. I know its frustrating, but stand your ground. I dont believe that the insurance is trying to cheat the provider out of anything, its just a product of most claims being processed without a "human" to verify these types of issues.
 
Good advice above. I'd add that if in fact this is the payer's policy and appeals don't work, then there's not much you can do to fight this. When a provider signs a contract with these commercial payers they are in effect agreeing to accept the payment policies that payer makes, so there isn't much that can be accomplished in trying to fight it.

In the end, this should really be looked at as a business decision: do the benefits of being in the contract outweigh the costs associated with the payment policies and other administrative burdens that the payer imposes on the provider? It's a good idea to track and quantify these things so that your provider can understand the costs involved. It can also be used as a good negotiating tool when the contract comes up for renewal - if you can show the payer hard figures that support the losses the practice incurs from those policies, that can be a strong bargaining chip to argue for increased rates across the board for the provider.
 
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