Wiki New Vs Est when hosp buy multiple groups

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susanb

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I was wondering if anyone has found in writing how patients are treated when the hospital buys several groups and a patient is seen in the different groups that are now under the same TIN? This is the breakdown that we got from Palmetto GBA as to how they look at it, of course it is not in writing on their website just from a customer service rep:

New vs. Established Patient – What is considered “Group”

Per Palmetto GBA (along with CMS), they look at the TIN FIRST and then the Specialty within that TIN. The technical term of Group is NOT driven by group NPI's but is driven by TIN.

Palmetto GBA and CMS first look at the TIN to determine the group. Then they look at the specialty taxonomy within that group to distinguish if it is payable as New vs. Established or same-day services.


Any help on this would be greatly appreciated.
 
Sorry, this may be more of a billing question than a coding question. I would say you would have to check with the major insurances that the group is contracted with to be sure -- but my guess is they would treat all of the entities of the same specialty within that group as being the same.

I can't give you a definite answer, but one of my clients is a multi-hospital group and they treat patients as established even if they have never been seen at that location before, but they have been seen by another provider of the same specialty within the group. I think this is because they have the same TIN and specialty, and they all share the same EMR so they have access to the records, which is really the reason why a new patient is paid at a higher rate - all that work of establishing a new record.
 
We frequently acquire groups....

If the patient is a patient of our established primary care provider, and then goes to see a specialist (that they never have seen before in the group's old practice) and are seeing them in our owned practice, the patient is still new to the specialist. TIN doesn't apply with providers of different specialties.

If the patient saw the specialist in their old practice, and are now coming to see the specialist in our practice, they are still established. Again, TIN plays no part here. They are the providers' established patients. If this new practice hires a new specialty provider, and the patient who saw the providers in the old practice in the past now comes in only to see the new provider, then they're a new patient. There is no relationship of the new provider with the old practice.

Hope this helps.
 
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