Wiki New Patient Visits

[jthomas]

I'm located in the Highmark Medicare Services jursidiction area and work for a large medical group. We have a large number of PAs and CRNPs working with our doctors. Medicare does not credential our PAs or CRNPs as to which specialty they practice with. Highmark Medicare Services is denying all our new patient visits if the patient was previously seen by another provider. For example, the patient had seen his PCP who happened to be a PA. The PA requested the service of an orthopedist. The patient is now seeing a M.D. at the orthopedist office as a new patient. Medicare will deny the orthopedic visit as new patient qualifications not met. We appeal to the QIC. The QIC denys stating the patient was previously seen by a physician/non-physician practioner within the last 3 year. New patient quarlification have not been met. We appeal these services as far as an ALJ. Are there any other jurisdictions out there denying for the same reason?

 

[btadlock1]

I'm located in the Highmark Medicare Services jursidiction area and work for a large medical group. We have a large number of PAs and CRNPs working with our doctors. Medicare does not credential our PAs or CRNPs as to which specialty they practice with. Highmark Medicare Services is denying all our new patient visits if the patient was previously seen by another provider. For example, the patient had seen his PCP who happened to be a PA. The PA requested the service of an orthopedist. The patient is now seeing a M.D. at the orthopedist office as a new patient. Medicare will deny the orthopedic visit as new patient qualifications not met. We appeal to the QIC. The QIC denys stating the patient was previously seen by a physician/non-physician practioner within the last 3 year. New patient quarlification have not been met. We appeal these services as far as an ALJ. Are there any other jurisdictions out there denying for the same reason?

We have a similar issue - some of our hospitalists employ PA's/FNP's, who see patients during an inpatient stay. If 2 FNP's see the patient the same day for 2 separate conditions, we have an extremely difficult time getting both paid. Their supervising MD's are different specialties (like GI and IM), but there's no way to identify that on the FNPs' claims, when criteria for incident-to billing hasn't been met. I called our MAC (Trailblazer) to see if there's any way around having to appeal a denial with records to get both providers paid, and was told that there's not. Just another example of bureaucratic waste, if you ask me.

I'm surprised to see you running into this issue, billing different provider types, though. That's contrary to CPT's definition of a 'New' patient.

 

[jthomas]

We have inpatients services deny also, but we can usually appeal with different diagnoses and documentation. Our main concern are our new patient denials. We wanted to know if other MACs are denying.