Provider-Based Billing

What does “Provider-based” or “Hospital Outpatient Clinic” mean?

“Provider-Based” or “Hospital Outpatient Clinic” refers to the billing process for services provided in a hospital outpatient clinic or location. This is a Medicare status for hospitals and clinics that meet specific Medicare regulations and requires that we bill Medicare in two parts (Part A and Part B). Tricare and Blue Cross/Blue Shield will also follow these same rules.

How does this affect patients?

Patients may receive a charge from the hospital and the doctor in a hospital outpatient clinic. If a patient has insurance, each patient’s insurance plan is unique to that patient and the contracted provider. Some insurances companies may cover both hospital charges and doctor charges and some may not.

What should I ask my insurance carrier?

Ask whether the insurance company covers facility charges in an outpatient hospital clinic. If it does, ask what percentage of the charge is covered. Additionally, verify what your hospital outpatient insurance benefits are, as they typically are applied toward a hospital deductible and coinsurance payment.

How does this affect a patient who has Medicare, Tricare or Blue Cross/Blue Shield?

In a hospital-based outpatient clinic, these patients may receive two (2) separate bills for services provided in the clinic – one from the doctor and one from the hospital.

Does this affect patient co-pays or deductibles?

Depending on the clinical service being provided, additional out-of-pocket expenses for these patients may be incurred in the “Provider-Based” clinic.

What if a patient has secondary coverage?

Co-insurance and deductibles may be covered by a secondary insurance policy. Check with your benefits or insurance company for details related to your 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 toward your deductible and coinsurance.