Wiki new vs established patient and insurance

[Lunap99]

I recently started working at a new clinic. There is only 1 provider here. For the most part I only have to look at how long it has been since their last visit to determine if they are new or established. The doctor came out today and told us we need to start indicating if the insurance has changed since the last visit so she knows if she can bill a new or established visit because we get paid more for new visits. I have never read anything indicating that insurance was a factor in determining new vs established status. I am looking for others' opinions on this before I bring it up to the doc.
It sounds to me like she is manipulating the system because the new insurance will not know if they have been seen before. Is insurance really a factor or is the doctor billing this wrong?

 

[carlystur]

That's because that's not how that works. The only thing that determines whether or not the patient is established is in our E/M guidelines of whether or not it has been at least 3 years since this particular provider has seen the patient. You are correct. Insurance has no factor in determining whether a patient is new or established.

 

[xXxPARAGONxXx]

I recently started working at a new clinic. There is only 1 provider here. For the most part I only have to look at how long it has been since their last visit to determine if they are new or established. The doctor came out today and told us we need to start indicating if the insurance has changed since the last visit so she knows if she can bill a new or established visit because we get paid more for new visits. I have never read anything indicating that insurance was a factor in determining new vs established status. I am looking for others' opinions on this before I bring it up to the doc.
It sounds to me like she is manipulating the system because the new insurance will not know if they have been seen before. Is insurance really a factor or is the doctor billing this wrong?

Sheesh. That's fraud.

I think you already know that, though. I'm sorry you've been put into that situation. Just e-mail [and BCC your personal e-mail] the provider the AMA guidelines on determining new versus established, and let her kindly know that unfortunately it would be unethical for you to submit a claim for an established patient as a new patient — just because the patient's insurance has changed — in order to get paid more.

And, well, that could go one of two pays, but you really have nothing to lose. Either the provider recognizes they are asking you to commit fraud and is understanding of their error, or the provider terminates you knowing full well they are asking you to commit fraud and you are unwilling to comply.

If you want to escalate it to litigation [for wrongful termination], you'll need proof in writing (hence, the e-mail). Not sure if it's worth the effort. If not, I'd just put in two weeks, not burn any bridges, and hope that the provider is decent enough to give you a good reference in the future.

Things like this show why it is necessary for coders to be unionized in order to be protected from unscrupulous providers and management.

 

[Lunap99]

I appreciate the responses. I was certain that insurance did not have anything to do with it but I am still fairly new and wanted validation. I am a temp and have already taken steps to be reassigned.