What does it mean to be provider-based?

A “Provider-Based” or “Hospital Outpatient Clinic” refers to services provided in hospital outpatient departments that are clinically integrated into a hospital. The clinical integration allows for higher quality and seamlessly coordinated care.

What is a provider-based entity?

A provider-based entity comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at the facility.

What is a CMS provider-based facility?

A provider-based entity comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility.

What is a remote location of a hospital?

“Remote location of a hospital: means a facility or organization that is either created by, or acquired by, a hospital that is the main provider for the purpose of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider, in accordance with the …

Is provider-based billing only for Medicare?

Thus, only patients with Medicare, Medicare Advantage and Tricare insurance are billed using provider-based billing. At this time, commercial insurance companies do not require this breakout.

How do you explain provider-based billing to patients?

Provider-based billing is the practice of charging for physician services separately from building/ facility overhead. This is an increasingly common way for hospitals to operate their outpatient facilities because it can cover for additional costs.

What is the definition of provider-based billing?

Provider-based billing is the practice of charging for physician services separately from building/ facility overhead. When patients visit a physician office that is part of a hospital’s outpatient department, Medicare pays a facility fee to the hospital and a reduced fee for the physician’s services.

What does Hopd stand for?

Hospital Outpatient Department (HOPD) Costs Higher than Physician Offices Due to Additional Capabilities, Regulations | AHA.

What is the 250 yard rule?

The 250-yard rule comes from the definition of “Campus” found at 42 CFR 413.65: A person who presents anywhere on the hospital campus and requests emergency services, or who would appear to a reasonably prudent person to be in need of medical attention, must be handled under EMTALA.

How does provider-based billing work?

In the provider-based billing model, also commonly referred to as hospital outpatient billing, patients may receive two charges on their combined patient bill for services provided within a clinic. One charge represents the facility or hospital charge and one charge represents the professional or physician fee.

What does billing provider mean?

Billing Provider means a person, agent, business, corporation, or other entity who, in connection with submission of claims to the Department, receives or directs payment from the Department on behalf of a performing provider and has been delegated the authority to obligate or act on behalf of the performing provider.

Who are hospital based providers?

hos·pi·tal·ist. 1. A physician whose professional activities are performed chiefly within a hospital (e.g., anesthesiologist, emergency department physician, intensivist (intensive care specialist), pathologist, and radiologist).

What does provider based status mean in CMS?

“Provider-based status: means the relationship between a main provider and a provider- based entity or a department of a provider, remote location of a hospital, or a satellite facility, that complies with the provisions of this section.”

What are the rules for provider based clinics?

A provider-based clinic must meet Medicare provider-based regulations. 2. Must a provider-based clinic be on the main campus of the provider? No, a provider-based clinic may be on the same campus as the main provider or located off campus.

What are the requirements for a CMS determination?

1 (1) Determination and review. If CMS learns that a provider has treated a facility or organization as provider -based and the provider did not request a determination of provider-based status 2 (2) Exception for good faith effort. 3 (3) Notice to provider. 4 (4) Adjustment of payments. 5 (5) Continuation of payment.

When to file an attestation with the CMS?

An attestation can be filed at any time to receive the determination from CMS. If the clinic operates as provider-based and is billing as provider-based, it is advisable to file an attestation and have the clinic designated provider-based.