New! Rule of the Month: New Patient Alert
We’re excited to bring you the Rule of the Month. A new athenaPulse feature, each month we’ll highlight a special insurance rule that makes your practice life easier and more profitable.
What’s a rule?
Part of athenahealth’s offering is unrivaled proprietary payer knowledge. We’re constantly working behind the scenes to make sure practices submit “clean” claims so that payers process them quickly and efficiently. As we investigate denials and track industry and client payment trends, we build rules that help individual practices avoid making mistakes that can delay payment and cause hassles for the billing staff. As a result, we maintain the largest real-time database of payer rules and regulations in the industry (for payers, procedures, diagnosis, appointment types, and more), updated constantly and shared by all clients.
The problem
Who’s a new patient?
You may know that the AMA’s 2007 CPT Manual defines a new patient as “one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.”
When you classify a patient as “new,” you may not have time to go through the patient’s record to verify they haven’t been seen in the past three years by a physician of the same specialty. And if the patient has, in fact, been seen in that time frame, the payer may reject the charge.
“It’s very difficult for providers and practices to quickly see the three-year history of every patient they classify as ‘new,’” said Maureen Loukas, athenahealth’s rules and format associate. “Most practices are simply focused on entering charge information.”
The solution
What if you could instantly search the patient’s record, alert the staff to the misuse of the new patient code if needed, and avoid the denied “new patient” claim?
This month’s rule does just that. After you enter a new patient code in the charge screen, our software automatically checks the patient’s three year history to make sure they are, indeed, new according to the CPT definition. The charge is then adjudicated on the first submission and you avoid the expense and hassle of re-working the claim.
What’s more, should the CPT definition of a “new” patient change, our software can quickly and automatically incorporate new parameters into our rules engine. That means you don’t have to scramble to update your software or billing procedures should definitions change (and they do!). The result: fewer denied claims, better cash flow, and streamlined patient processing.
Stay tuned for next month’s rule.