Wiki New vs Est. Patient

[vanessa_rae_s@yahoo.com]

I file a lot of claims to no-fault. If a patient is seen for accident #1 this makes them established. Would they still be considered established for accident #2? Even with a different claim #, different injury, etc? I say established but I'm being told no. Please help!

 

[danskangel313]

This can get tricky because "insurers providing only workers’ compensation, automobile insurance, and property and casualty insurance are not considered to be health plans." (aka not a covered entity under HIPAA)

Personally I don't think it would really be fair to any subsequent, unrelated insurers (not health plans) to be forced into est only because another insurer got to the hospital first (as far as DOS and billing). However, state laws can vary about this, so there isn't a real "blanket" answer.

I know of a few states that say "it's a new patient visit when it's a new injury." But once the patient has been seen for injury #1, any visits after the initial new pt will be subsequent when related to that injury. For injury #2 the same applies, any visits after the initial new pt will be subsequent when related to that injury.

I did a quick search and found this for Colorado (as an example of the language):
New or Established Patients
An E&M visit shall be billed as a "new" patient service for each
"new injury" even though the provider has seen the patient within the
last three (3) years. Any subsequent E&M visits are to be billed as
an "established patient" and reflect the level of service indicated
by the documentation when addressing all of the current injuries.
Transfer of care from one physician to another with the same tax ID
and the same specialty shall be billed as an "established patient"
regardless of the location.

Hope that helps!