For patients who have Medicare, Medicare Advantage and Tricare insurance, Mayo Clinic Health System – Franciscan Healthcare bills the services as “provider-based billing” (sometimes called hospital-based billing).
What is provider based billing?
Provider-based billing is a type of billing for services provided in a clinic or department which is considered to be part of the hospital. This is often the case with large health care systems. Clinics located several miles away from the main hospital campus may be considered part of the hospital. Even though you’re seeing your regular physician in a clinic setting and not actually “hospitalized,” your visit is billed under the hospital rather than the physician’s office.
Affected patients see a statement with charges split apart for each visit – one charge will be a professional fee (clinic charge) and the other a technical fee (hospital charge). The combined total charge is the same, but the components are split apart. Depending on specific insurance coverage, it is possible that some benefits may differ for these services and procedures. Some patients may have to pay a higher cost because a portion of the billed service is being charged as a hospital charge. The increase in cost is a result of the health plan’s co-insurance and deductible (not an increase in actual fees). Patients with a supplement plan are not likely to see much change.
Why provider-based billing?
This is the national model of practice for large, health care networks where the hospital owns space and employs support staff who assist with patient care. It is used by many medical centers, both locally and across the country. This benefits patients as all departments of the hospital are subject to strict quality standards and are monitored by The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 17,000 health care organizations and programs in the United States. Medicare and Medicaid have distinct payment programs for Provider Based Billing, and require that we make it clear to the public which practices are part of the hospital.
Are appointments different under provider-based billing?
Clinical care is the same. Patients continue to see their regular doctor and health care team and continue to receive excellent quality care. Scheduling appointments and tests are handled the same. Medicare patients are asked to complete an “MSP questionnaire” on every visit which contains 10-15 questions. We recognize this may feel repetitive but it is a government requirement. We provide patients with a handy reference card to assist with this process.
Are all patients being billed this way?
No. The requirement for breaking out charges for each office visit was set by the Centers of Medicare and Medicaid. 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.
What can you do if you are having difficulty paying for health care services?
Our charity care program exists to help qualifying patients. Information is available by calling 800-603-2500 (toll-free). In addition, we can assist with other county, state or national coverage programs that patients may be eligible for.