我和丈夫在2018年4月首次去了一家IVF诊所，进行试管婴儿的初次咨询。2018年我们没有在诊所做任何检查，因为后来我自然怀孕了。2024年6月，我们再次找到了同一位医生进行咨询。这次医生把我们当成新病人，没有提出具体的治疗建议，只是开了几项检查，包括经期第三天的血液检查和宫腔镜检查。他说需要先查看我的激素水平等，才能给出治疗方案。 然而，这家IVF诊所告诉我们，这次咨询的200美元费用需要自付，他们认为这是“治疗咨询”（treatment consultation），而不是“诊断咨询”（diagnostic consultation），所以不能通过保险报销。但我之前在其他诊所的咨询，至少有10%的费用是可以报销的。现在这家诊所不愿意帮我把这次的咨询费用提交给保险公司。 我对此有些疑惑，因为在咨询中，医生没有做任何诊断，也没有给出治疗建议，只是开了检查的单子，单据上也写明了是“诊断测试”（diagnostic tests）。但诊所坚持认为2018年的那次是初次咨询，这次是跟进咨询，所以要自付费用。 **诊所的回复如下**： > Hello, Good morning! > I apologize for the late reply. I was out last week and just getting back with my messages. I reviewed your account and upon checking your 06/12/24 consultation, it is a Treatment consultation which is an exclusion from your policy (Diagnostic Only coverage). The self-pay fee for the consultation is $200 minus a $50 downpayment and a $78.35 credit card charge on the day of the consultation, which makes up the $71.65 balance on your account. 我想请问大家，这样的收费合理吗？他们把这次咨询算作治疗咨询是否有依据？如果不合理，我该如何处理？是否可以向相关部门投诉？谁是相关部门？ 非常感谢大家的建议和帮助！
附上来回邮件，基本就是拉锯 我： Hi, Thank you for your patience. We were unsuccessful reaching you by phone. This appointment potentially would be covered -- at least partially - by insurance if the appropriate codes were assigned. For example: Diagnosis = Z31.69 Procedure = 99443 Would it be possible to submit this appt as a telehealth call to our insurance? thank you 诊所: Hello, your 6/12 Follow-up consultation is considered as a Treatment consultation, and upon checking your policy it is a Diagnostic only for infertility and has no treatment coverage which makes it a non-covered service. Our billing department was provided by your insurance with codes to submit and has a standard infertility diagnosis code to use when submitting to insurance. Unfortunately, we are not allowing by insurance to submit claims to insurance with non- covered services. 我: Hello, Thank you for your reply. I understand that you categorized my visit on 06/12/24 as a "Treatment consultation," but I would like to clarify that during the consultation, no treatment was offered or provided. The doctor only prescribed tests as part of an initial evaluation, which aligns with a diagnostic-only consultation. Given this, could you please review my account and consider this under the "Diagnostic Only" coverage? I appreciate your assistance in resolving this matter. 诊所: I have consulted this with my Lead and our coding team, however, they have confirmed that follow-up consultation for Insurance coverage that has Diagnostic-only coverage is at our self-pay pricing and a non-covered service for the Specialist''s clinic. This cannot be fall unto a New Patient appointment. I hope I can do more about this however there are standard policies we need to follow with your insurance. 我: Hello, Thank you for your response. However, I would like to clarify a few points: Our first appointment with your clinic was in 2018, and we did not receive any treatment following that initial consultation. Since then, we have not had any follow-up appointments, treatments, or ongoing care from your clinic. The appointment we recently scheduled is a **new patient** appointment, as we are starting fresh with your clinic. There is no existing treatment plan or follow-up to discuss; everything is starting anew. The tests that Dr. Nash has prescribed are new patient tests, not follow-up diagnostic tests, which is why it should not be coded as a follow-up consultation. Additionally, your clinic has coded these tests as diagnostic, but I have not received any diagnostic services or treatments before this. It doesn''t make sense to consider this as a follow-up when there hasn''t been any prior diagnostic procedure or treatment in place. I understand there are standard policies to follow, but given these circumstances, I believe this appointment should be categorized as a new patient visit, not a follow-up. I would appreciate it if you could review this situation again in light of this information. Thank you for your understanding.
From ChatGPT: In most medical practices, the distinction between a "new patient" and an "established patient" is based on the length of time since the last visit. According to the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS), a "new patient" is someone who has not received any professional services from the physician (or another physician of the same specialty within the same practice) within the past **three years**. Since your last visit was five years ago, your recent visit would generally be categorized as a **"new patient"** visit, not a "follow-up" visit. 鉴于ChatGPT也时不时胡说，建议你还是去这个AMA/CMA查查是不是有“只要三年没去这家诊所看过就算新病人”这一说。如果有的话，你应该可以继续argue。另外，你应该也给自己的保险公司打电话问问。
jennyalger 发表于 2024-08-28 21:51 From ChatGPT: In most medical practices, the distinction between a "new patient" and an "established patient" is based on the length of time since the last visit. According to the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS), a "new patient" is someone who has not received any professional services from the physician (or another physician of the same specialty within the same practice) within the past **three years**. Since your last visit was five years ago, your recent visit would generally be categorized as a **"new patient"** visit, not a "follow-up" visit. 鉴于ChatGPT也时不时胡说，建议你还是去这个AMA/CMA查查是不是有“只要三年没去这家诊所看过就算新病人”这一说。如果有的话，你应该可以继续argue。另外，你应该也给自己的保险公司打电话问问。
然而，这家IVF诊所告诉我们，这次咨询的200美元费用需要自付，他们认为这是“治疗咨询”（treatment consultation），而不是“诊断咨询”（diagnostic consultation），所以不能通过保险报销。但我之前在其他诊所的咨询，至少有10%的费用是可以报销的。现在这家诊所不愿意帮我把这次的咨询费用提交给保险公司。
我对此有些疑惑，因为在咨询中，医生没有做任何诊断，也没有给出治疗建议，只是开了检查的单子，单据上也写明了是“诊断测试”（diagnostic tests）。但诊所坚持认为2018年的那次是初次咨询，这次是跟进咨询，所以要自付费用。
**诊所的回复如下**：
> Hello, Good morning! > I apologize for the late reply. I was out last week and just getting back with my messages. I reviewed your account and upon checking your 06/12/24 consultation, it is a Treatment consultation which is an exclusion from your policy (Diagnostic Only coverage). The self-pay fee for the consultation is $200 minus a $50 downpayment and a $78.35 credit card charge on the day of the consultation, which makes up the $71.65 balance on your account.
我想请问大家，这样的收费合理吗？他们把这次咨询算作治疗咨询是否有依据？如果不合理，我该如何处理？是否可以向相关部门投诉？谁是相关部门？
非常感谢大家的建议和帮助！
附上来回邮件，基本就是拉锯
我：
Hi, Thank you for your patience. We were unsuccessful reaching you by phone.
This appointment potentially would be covered -- at least partially - by insurance if the appropriate codes were assigned.
For example: Diagnosis = Z31.69 Procedure = 99443
Would it be possible to submit this appt as a telehealth call to our insurance?
thank you
诊所:
Hello, your 6/12 Follow-up consultation is considered as a Treatment consultation, and upon checking your policy it is a Diagnostic only for infertility and has no treatment coverage which makes it a non-covered service. Our billing department was provided by your insurance with codes to submit and has a standard infertility diagnosis code to use when submitting to insurance. Unfortunately, we are not allowing by insurance to submit claims to insurance with non- covered services.
我:
Hello,
Thank you for your reply. I understand that you categorized my visit on 06/12/24 as a "Treatment consultation," but I would like to clarify that during the consultation, no treatment was offered or provided. The doctor only prescribed tests as part of an initial evaluation, which aligns with a diagnostic-only consultation.
Given this, could you please review my account and consider this under the "Diagnostic Only" coverage? I appreciate your assistance in resolving this matter.
诊所:
I have consulted this with my Lead and our coding team, however, they have confirmed that follow-up consultation for Insurance coverage that has Diagnostic-only coverage is at our self-pay pricing and a non-covered service for the Specialist''s clinic. This cannot be fall unto a New Patient appointment. I hope I can do more about this however there are standard policies we need to follow with your insurance.
我:
Hello,
Thank you for your response. However, I would like to clarify a few points:
Our first appointment with your clinic was in 2018, and we did not receive any treatment following that initial consultation. Since then, we have not had any follow-up appointments, treatments, or ongoing care from your clinic.
The appointment we recently scheduled is a **new patient** appointment, as we are starting fresh with your clinic. There is no existing treatment plan or follow-up to discuss; everything is starting anew. The tests that Dr. Nash has prescribed are new patient tests, not follow-up diagnostic tests, which is why it should not be coded as a follow-up consultation.
Additionally, your clinic has coded these tests as diagnostic, but I have not received any diagnostic services or treatments before this. It doesn''t make sense to consider this as a follow-up when there hasn''t been any prior diagnostic procedure or treatment in place.
I understand there are standard policies to follow, but given these circumstances, I believe this appointment should be categorized as a new patient visit, not a follow-up. I would appreciate it if you could review this situation again in light of this information.
Thank you for your understanding.
请问自己提交是不是我自己找垫付200块咨询费，然后保险公司如果通过的话退我钱？但是我觉得在没有任何诊断检查之前，就把咨询定为follow up treatment consultation很不合理
Since your last visit was five years ago, your recent visit would generally be categorized as a **"new patient"** visit, not a "follow-up" visit.
鉴于ChatGPT也时不时胡说，建议你还是去这个AMA/CMA查查是不是有“只要三年没去这家诊所看过就算新病人”这一说。如果有的话，你应该可以继续argue。另外，你应该也给自己的保险公司打电话问问。
非常感谢有用信息，我去查查。
是的。
谢谢
谢谢。如果是他们不合理，我就是再花时间也要争一下，就当了解新知识新体验。刚查了下当地小额法庭78美金，如果道理在我这边，我体验下小额法庭。
就算是200也不值得吧 你现在年轻 时间更值钱 等老了没事干了再到处讲理去
我在其他诊所无论是initial 还是follow up都能报销的是90%，但是这家都不帮我提交。
第一次遇到这种事，如果怎么不能解决，医疗机构就无法被投诉吗？商场起码还有BBB，遇到诊所，真是无门申诉吗？
3年，可以算新病人，但不是一定要算新病人，诊所有权自己决定的。
主要是保险公司批不批，和是诊所还是你submit没关系
谢谢。请问医生开的是 diagnostic test，开diagnostic tests前的咨询能算treatment consultation吗？没有检验报告怎么treat？
自己提交相关的code也是自己定吗？
谢谢，不敢碰它家了。其他几家无论初诊还是复诊我都只交10到18美金。
你要看procedure code, 不要看“treatment consultation”.
对于自己claim我不是很熟， 但是我相信自己claim也需要诊所提供的documentation. 总之你要和诊所还有保险公司打交道，费时费力，你抓紧时间得到treatment ，安心备孕才是最重要的。
再说没有任何检验报告，当然可以算treatment consultation啦。 问诊的过程就是为了treat 你的怀孕问题的咨询过程。
他只问了我们试了多久了，我们说试了一年了，然后他说要测这个这个这个，他才能告诉我可能性多大。过程中没有任何关于提高卵子质量的建议，也没有任何关于protocol的建议，他调整摄像头，他让我们两个调整摄像头以让其中某一个人居中，占了60%的时间。在其他诊所的医生都不像这个医生那样几句话打发的。到头来他收费最贵，这也是我觉得惊讶的地方。