Provider-Based Billing FAQ
What can patients expect to see on their bill for a provider-based clinic?
According to Medicare billing rules, when patients see a provider in a private office setting, all services and expenses are bundled into a single charge. When patients see a provider in a provider-based clinic, provider (professional) and clinic (facility) charges are billed separately.
Visits to provider-based clinics will result in two charges for the patient:
First Charge
A facility charge from the hospital, which covers the use of the room and any medical or technical supplies, equipment, and support staff.
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Second Charge
A professional or provider charges for outpatient services and/or procedures from the medical provider you see.
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Previously, you may have seen all services and expenses in one single charge.
For patients with insurance, provider services will be processed under provider benefits, which are generally subject to patient copays. Hospital services will be processed under hospital benefits and subject to deductibles and coinsurance.
Will patients experience higher out-of-pocket costs for being seen in a provider-based clinic versus a freestanding office?
The cost for the patient depends on the patient's insurance coverage. Benefits may vary for some services at hospital facilities. Most patients seen in a provider-based clinic will have higher out-of-pocket costs compared to being seen in a freestanding provider's office location. Patients who do not have a secondary or supplemental payer are more likely to experience higher out-of-pocket costs at these locations.
Insurance benefits vary significantly by insurance company, but in general, provider services are processed under the benefit plan’s provider benefits and are subject to co-payment amounts from the patient. Laboratory and radiology services provided by the hospital are billed by the hospital regardless of the type of insurance. Hospital services are generally processed under the benefit plan’s hospital benefits and are subject to deductibles and coinsurance amounts.
Does this only apply to certain insurance carriers?
The requirement to list professional services and facility charges separately is unique to the Centers for Medicare and Medicaid. If a patient has private insurance, each patient’s insurance plan is unique to that patient and the contracted provider. Some insurance companies may cover both hospital charges and provider charges, and some may not.
What should patients ask their insurance carrier?
Making informed healthcare decisions is important. Patients may want to ask their insurance company the following:
- Does my benefit plan cover facility charges in a provider-based/ hospital outpatient clinic?
- How much of the charges (what percent) are covered by my plan?
- Will the charges be applied to my deductible or subject to coinsurance?
What if a patient has secondary coverage?
Co-insurance and deductibles may be covered by a secondary insurance policy. Patients should check with their benefits or insurance company for details related to their secondary coverage. For instance, you may ask whether the secondary insurance company covers facility charges or provider-based billing. If it does, ask what percentage of the charge is covered. Verify what your hospital outpatient insurance benefits are, as they typically are applied towards your deductible and coinsurance.
Who can patients call if they have more questions about provider-based clinic costs or their bills?
If patients have additional questions about provider-based costs or their bills, they should first contact their insurance provider to ensure they understand their current insurance benefits. Then, if needed, they should reach out to the patient financial services department at BVHS for further assistance at 419.423.5310.
Who can patients speak to if they need to discuss payment arrangements or a payment plan or if they are having difficulty paying for their bills received by Blanchard Valley Health System?
Please call the BVHS patient financial services department at 419.423.5310.
How much can patients expect to pay out of pocket for services at a provider-based clinic?
Out-of-pocket costs can vary greatly in a provider-based clinic for services provided and are based on the patient’s specific benefits. Please visit our online cost estimate tool if you have questions or would like a personal estimate specific to a certain service. If the service you are looking for is not listed, please contact us by phone at 419.425.5252
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