Wiki uninsured to newly insured billing question

[donsgirl1015]

One of my providers is asking about billing for a patient. He has not had insurance before, the provider has seen the patient but has pretty much written off the billing. He now presents with insurance coverage and Dr. is asking about billing new patient codes. **key point in providers mind is "this has not been billed to any insurance". My gut reaction is it is NOT a new patient,because patient has been seen within the last 3years, but of course - i need some black & white regulations to show/back up this train of thought. Has anyone else dealt with this scenario, any resources that deal with patients who are newly insured? Appreciate your help/insight/references!
Melissa

 

[MarcusM]

You cannot bill a "new" patient CPT code for an established patient: "New patient" is defined as a patient who has not received any professional services from the physician within the previous three years. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If no face to face encounter has previously occurred between the physician and the patient, then the patient may be coded as a new patient the first time a face to face encounter does occur." Do you currently bill established patients as "new" patients when their insurance plan changes from BCBS to Aetna? The big question is what happens when this insurance requests "all the medical records" on this newly insured patient? Which they are apt to do....it is just not worth the risk for a "few dollars more."

 

[donsgirl1015]

Marcus, my thoughts exactly - i used the same example of switching insurances. thank you for the support!

 

[airart]

Black and White in Writing Proof

If your physician would also like to see the definitions of what a new patient or established patient then refer them to the CPT book E&M section in the beginning of the book. The definitions are detailed for coding.

Plus, from an auditor's view point, if the chart is ever audited how are they going to explain billing for a new patient code when there are existing medical notes in the file for previous visits?