Provider-Based Billing FAQs
Platte Valley Medical Clinic is a hospital-based clinic.
Here are answers to frequently asked questions about this type of clinic and provider-based billing.
What does 'hospital-based' mean?
This has become a common national model of practice for integrated health care delivery. Hospital-based clinics are subject to more strict government rules and higher quality standards than private physician clinics. Hospital-based clinics must comply with Medicare facility accreditation standards and are surveyed on a regular basis to ensure compliance with standards.
The physician you see will not change. The Platte Valley Medical Clinic physicians that you have always known and that have been part of Kearney since 1956 will continue to practice out of Platte Valley Medical Clinic.
How long does this affect billing?
According to Medicare billing rules, when you see a physician in a “private physician” clinic, all services and expenses are bundled in a single charge. With the “hospital based” model, patients receive two (2) bills. One (1) bill represents the facility charge and one (1) bill represents the physician fee or professional charge.
How does this affect a patient's out-of-pocket expense?
Depending on the particular insurance coverage, benefits like co-pays, coinsurance and deductibles may affect out-of-pocket expense and may differ for certain outpatient/clinic services at hospital-based clinics. We recommend patients review their insurance benefits or contact their insurance provider to determine what out-of-pocket expense they may incur.
Does this apply to patients with private insurance like Blue Cross Blue Shield, United Healthcare, Midlands Choice, Coventry or Aetna?
Many private insurance companies do not require that we follow the same billing rules (i.e. – one bill for professional and one bill for facility) required by Medicare and Medicaid. For patients with private insurance, the facility component of the physician office visit will be bundled and billed as part of the physician bill and will be processed by the insurance company under the patient’s physician benefits. Although private insurance benefits vary from one company to another physician services are generally processed solely under the “physician benefits” portion of the plan and are subject to patient co-pays.
Outpatient departments within the hospital, such as Laboratory and radiology services, are provided by the hospital and are billed by the hospital regardless of the type of insurance. Hospital services are generally processed under the insurance plan’s “hospital benefits” and are subject to patient deductibles and coinsurance.
How does this affect a patient who has Medicare, Medicare Advantage or Medicaid?
In a hospital-based clinic, Medicare and Medicaid patients will receive two (2) separate bills (i.e. – one for professional fees and one for facility fees) for services provided in the clinic. Adult Medicaid patients will be required to pay two (2) co-payments for the clinic visit (i.e. – one for the physician visit and one for the hospital visit).
For patients covered by Medicare and Medicare Advantage, hospital/facility fees will be subject to coinsurance and deductibles.
What if a Medicare patient has secondary insurance coverage?
Your secondary insurance may cover your coinsurance and deductibles. Check with your insurance company to find out.
Why does the Medicare Secondary Payer (MSP) questionnaire need to be completed?
As a participating Medicare Provider, we are required to screen Medicare patients according to the MSP rules. At each visit, you will be asked the MSP questions. These questions help us confirm if Medicare or another payer should process your insurance claim as primary.
Where can a patient call with financial questions or concerns, or if having difficulty paying their bill?
Kearney Regional Medical Center’s financial services representatives are able to assist you with your questions. If you have an upcoming appointment, questions about your bill or are having difficulty paying your bill, please contact us at 308-865-2263.
If you are having difficulty paying your bill, please contact a patient financial representative at 308-865-2263 to discuss available payment options.