Note: This question is specific to the Medicare FQHC new patient definition. For non-Medicare FQHC patients, see – Established Patient Follows Provider to New Clinic.
Q:
We have recently had providers join our team from other clinics and their patients have followed them. Can you tell me where I can find the guidelines for whether this a new Medicare FQHC patient if the patient is new to our clinic but has seen the provider at his previous clinic?
A:
A new FQHC Medicare patient is defined in several places including Chapter 13 of the Benefit Policy Manual. This definition is specific to Medicare FQHC and does not follow CPT’s definition. A new Medicare patient in the FQHC setting is defined as someone who has not received any Medicare-covered professional health service (medical or mental health) from any site within the FQHC organization, or from any practitioner within the FQHC organization, within the past 3 years from the date of service.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c13.pdf
Also, there is a very helpful Medicare FQHC FAQ posted at the CMS’ FQHC Center, https://www.cms.gov/center/provider-type/federally-qualified-health-centers-fqhc-center. It contains some great information including two Q&As on this very topic:
Q5. If a patient was seen in another FQHC that is not affiliated with my FQHC, and then came to my FQHC 6 months later, would they be considered a new patient?
A5. Yes, because they would be new to your FQHC.
Q6. If my FQHC hires a new physician, and patients from the physician’s previous private practice group follow the physician to our FQHC, are these patients considered “new patients”?
A6. Yes, because they are new to your FQHC.