Orthopedic Coding Alert

Question: I was on call at the ED and treated a patient there, then I saw that patient for follow-up care in my office. What happens if my practice doesnt accept the patients insurance?

Michigan Subscriber

 
Answer: Your staff should contact the patient prior to his first follow-up visit to determine if you participate with his health insurance. If not, he can contact his insurance carrier to request authorization to continue care with you or obtain a referral to a participating provider for follow-up care. If the patient is an HMO beneficiary with no out-of-network benefits and the insurance carrier will not authorize follow-up care, he must be advised that continued care with you will not be covered by his insurance. PPO patients have the option of seeking care out-of-network, usually with a higher out-of-pocket expense. In either case, if the patient opts to continue care with you, he should sign a statement of financial responsibility. The treatment rendered in the ED will most likely be covered, as most managed care plans include provisions for emergent care by nonparticipating providers.

 
-- Answers to You Be the Coder and Reader Questions provided by Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J.