Provider-Based Billing Questions and Answers
Q: What does ‘provider based’ mean?
A: Provider-based refers to the billing process for services rendered in a hospital outpatient clinic or location. This status requires that the clinic bill Medicare in two parts. This is the national model of practice for integrated delivery systems where the hospital owns space and employs support personnel involved in patient care.
Q: How does being provider-based affect billing?
A: Under the provider-based model, patients may potentially receive two charges on their combined patient bill. One charge represents the facility charge and one charge represents the professional or physician fee charge. Prior to being provider-based, all charges were grouped together on your patient statement.
Q: Why move to this billing process?
A: Patients admitted to hospitals have historically received more than one bill, one for hospital services and others for physician or professional services. Following this same type of billing services ensures more appropriate payment for services provided by hospital staff and physicians and distinguishes facilities that function as departments of hospitals from those which are free-standing.
Q: Does this mean patients will pay more for services?
A: Depending on a patient’s particular insurance coverage, it is possible that patients may pay more for certain outpatient services and procedures at our provider based locations than at another site. We recommend patients review their insurance benefits or contact their insurance provider to determine what their policy will pay and what out-of-pocket expenses may be incurred.
Please Note: The total cost of charges for Medicare patients will not exceed charges incurred by non-Medicare patients receiving the same services.
Q: Does this affect patient co-pays or deductibles?
A: Depending on each patient’s specific insurance benefits, additional patient out-of-pocket expenses may be incurred by the provider-based model.
Q: What are the provider-based locations under MEDWEST?
A: Harris/Swain/Franklin sites:
- Center for Family Medicine
- Ancillary Services of WestCare Medical Park of Franklin
- MedWest Urgent Care – Sylva
- Mountain Care Urology
- Western Carolina Pulmonary and Sleep Consultants
- Swain Medical Center
- Sylva Medical Center
B: Haywood sites
- Blue Mountain Urology
- Haywood Women’s Medical Center
- MedWest Urgent Care – West
- MedWest Urgent Care – Canton
- Waynesville Family Practice
- Western Carolina Cardiology
- Mountain Medical Associates
Other locations will be included as MEDWEST continues to expand services to meet patient needs.
For more information please contact us at (828) 631-8206 or (828) 631-8227 if you have further questions regarding Provider-Based billing.