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 that is a department of the hospital.  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: Are all patients being billed this way?
No. The requirement for breaking out charges for each office or service was set by the Centers for Medicare and Medicaid. Thus, only patients with Medicare, Medicare Advantage, Medicaid or TRICARE are being billed using Provider Based Billing. At this time, commercial insurance companies do not require HRMC to break out charges. 

Q: Why the change to Provider Based Billing?
It benefits patients as the practices are subject to rigorous quality standards and are monitored by The Joint Commission (TJC), a non-profit organization which accredits more than 20,000 health care organizations and programs in the United States. It is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. Healthcare providers who receive Joint Commission accreditation have proved that they provide the highest level of performance and service to their patients. 

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 Haywood Regional Medical Center?

  • Blue Mountain Urology
  • Haywood Regional Urgent Care – West
  • Haywood Regional Urgent Care – Canton
  • Waynesville Family Practice
  • Western Carolina Cardiology
  • Mountain Medical Associates

Other locations will be included as Haywood Regional Medical Center 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.