Provider Based Out-Patient Clinic FAQ
This conversion may impact patients who have one or more of the following plans: Medicare, Medicare Advantage, and Medicaid. Receiving care at ARMC locations, also known as Hospital Outpatient department will result in a hospital facility charge for outpatient services and/or procedures. These charges will be reflected on the patient statement you receive for services provided.
To help you to better understand this change, we've developed the following Frequently Asked Questions (FAQ) document:
What exactly is a Hospital-based outpatient clinic?
Hospital-based outpatient clinics are considered a department of the hospital; "private" physician offices are not. (generally, these are smaller physician offices out in the community). Clinics located miles away from the main hospital campus may still be considered part of the hospital. Hospital-based outpatient clinics are subject to stricter government rules, making them more complex and more costly to operate. When you see a physician or receive services in a hospital-based outpatient clinic, you are technically being treated within the hospital rather than the physician's office as these offices are now considered a department of the hospital.
What is the different about a hospital–based outpatient clinic?
According to Medicare billing rules, when you see a physician in a private office setting, all services and expenses are bundled into a single charge. When you see a physician in a hospital-based outpatient clinic, physician and clinic (facility) charges are billed separately.
For patients with insurance, physician services are processed under physician benefits, which are generally subject to patient liabilities in the form of co-payments while hospital services are processed under hospital benefits subject to deductibles and coinsurance amounts. Providing services in a hospital-based outpatient clinic costs more and depending on your insurance plan, may result in greater out-of-pocket expenses.
How does this affect a patient who has Medicare, Medicare Advantage or Medicaid?
In hospital-based outpatient clinics, Medicare and Medicaid patients could receive two (2) separate bills for services provided in the clinic – one from the doctor and one from the hospital. Adult Medicaid patients who have a spend down agreement will be required to pay for the clinic visit – and the facility fee until they have met their pre-determined spend down amount thru Medicaid. For patients covered by Medicare or Medicare Advantage plans, non-physician charges billed by the hospital will be subject to coinsurance.
What if a Medicare patient has a secondary insurance?
Where can a patient call with financial questions or concerns?
Coinsurance and deductibles may be covered by a secondary insurance. Check your benefits or with your insurance company for details.
ARMC has staff available to assist with questions. Please contact 989-356-7768.