Hospital-Based Outpatient Clinics
Wake Forest Baptist Medical Center has converted many of its physician clinics to hospital-based outpatient clinics. If you are covered by Medicare or a Medicare Advantage plan, or if you do not have insurance, your out-of-pocket costs for seeing a physician and receiving services in a hospital-based outpatient clinic will be more, compared to the out-of-pocket cost for the same services in a private physician office.
Laboratory and radiology services are provided by the hospital and are billed by the hospital regardless of the type of insurance.
Below are frequently asked questions (FAQs) related to hospital-based outpatient clinics:
Q: What does “Hospital-based Outpatient” mean?
A: Hospital-based outpatient clinics are considered part 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 being treated within the hospital rather than the physician’s office.
Q: What is different about a hospital-based outpatient clinic?
A: According to Medicare billing rules, when you see a physician in a private office setting, all services and expenses are bundled in a single charge. When you see a physician in a hospital-based outpatient clinic, physician and hospital 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 copayments 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 for you; particularly if you are covered by Medicare or a Medicare Advantage Plan, have insurance with companies with which WFBH does not have a contract (non-contracted private payers), or if you don’t have insurance.
Q: What should I ask my insurance carrier?
A: Making informed healthcare purchasing decisions is important. Ask your insurance company if your benefit plan covers facility charges in a hospital-based outpatient clinic and how much of the charge is covered or will be applied to your deductible or subject to coinsurance.
Q: Does this apply to patients with private insurance like Blue Cross Blue Shield, United Healthcare, MedCost, Cigna or Aetna?
A: Many private insurance companies do not require that we follow the same billing rules required by Medicare and Medicaid. For patients with private insurance, the facility component of the physician office visit will be billed as part of the physician bill and will be processed by the insurance company under the patient’s physician benefits. Insurance benefits vary significantly by insurance company, but in general, physician services are processed under the benefit plan’s physician benefits and are subject to co-payment amounts from the patient. 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 benefit plan’s hospital benefits and are subject to deductibles and coinsurance amounts.
Q: How does this affect a patient who has Medicare, Medicare Advantage or Medicaid?
A: In a hospital-based outpatient clinic, Medicare and Medicaid patients will receive two (2) separate bills for services provided in the clinic – one from the doctor and one from the hospital. Adult Medicaid patients will be required to pay two copayments for the clinic visit – one copayment for the physician visit and one copayment for the hospital visit. For patients covered by Medicare or Medicare Advantage plans, non-physician charges billed by the hospital will be subject to coinsurance.
Q: What if a Medicare patient has secondary insurance coverage?
A: Coinsurance and deductibles may be covered by a secondary insurance. Check your benefits or with your insurance company for details.
Q: Where can a patient call with financial questions or concerns?
A: Wake Forest Baptist Medical Center has staff available through Patient Financial Services to assist with questions. If you have an upcoming appointment, please contact 336-716-1663 or visit us on campus on the Main Floor, Reynolds Tower.
Q: Why does the Medicare Secondary Payer (MSP) questionnaire need to be completed?
A: 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.
Q: What can patients do if they are having difficulty paying for healthcare services?
A: They can contact a Patient Financial Services representative at 336-716-1663 to discuss available options.