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Common Provider-based Billing Questions

What is provider-based billing?

Provider-based billing is a type of billing for services rendered in a hospital outpatient department including a medical office. This billing model also is known as hospital outpatient billing. 

Why provider-based billing?

Provider-based billing is used by many integrated (hospital and medical office) health care systems across the nation, like Marshfield Clinic Health System. Patients benefit because all hospital outpatient departments are subject to additional stringent quality standards and are monitored by The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 21,000 health care organizations and programs in the United States. The Centers for Medicare and Medicaid have separate payment programs for provider-based billing and require us to make it clear to our patients which health care services are part of the hospital. 

How does provider-based billing affect the billing process?

For patients with certain insurance coverage, your billing statement for each visit or service you receive will show:

  • One charge for the professional services rendered by the provider you see; and
  • One charge for the facility, which covers the use of the room and any medical or technical supplies, equipment and support staff. 

For most patients, both charges add up to the same amount previously charged to all patients for the same service. 

Which Marshfield Clinic Health System locations are provider-based? 

Effective, June 1, 2018, our Marshfield campus is using provider-based billing. This is because health care services provided in the medical offices in Marshfield will be considered hospital outpatient services. 

In the future, other Marshfield Clinic centers, which are located on an integrated medical campus, will become hospital outpatient services. 

Will there be a change in how I receive care? 

No – how you receive care remains the same. You will continue to receive excellent quality care from the same providers you have come to know and trust. Scheduling for appointments and tests will not change. 

Are all patients billed using provider-based billing? 

The requirement to separately list professional services and facility charges for each office visit or service is required by the Centers for Medicare and Medicaid. Only patients with Medicare, TRICARE®, Veteran’s Administration, Medicaid or select Medicare Advantage plans are billed with the separately listed professional service and facility charges. 

Other payors, such as commercial insurance companies, do not require charges be shown and billed separately.

Will provider-based billing increase the cost of care for Medicare, Medicare Advantage, Medicaid, TRICARE®, or Veterans Administration-covered patients? 

Cost of care will depend on the particular insurance coverage. Benefits may be different for certain outpatient services at a provider-based billing location. Some Medicare patients may be covered by supplemental insurance and may not have to pay more out-of-pocket. 

Medicare beneficiaries are responsible for the co-insurance amount on the services received. The co-insurance amounts are determined by Medicare and based on the services performed. You will need to review your insurance plan to determine what is covered and what you are responsible for.