Hospital-Based Outpatient Clinics
Wake Forest Baptist has converted many of its physician clinics to hospital-based outpatient clinics. Hospital-based outpatient clinics are considered part of the hospital not a private physician office.
Clinics located miles away from the main hospital campus may still be considered part of the hospital. Because hospital-based outpatient clinics must follow stricter government rules, they are more complex and more costly to operate.
A hospital-based outpatient clinic is different than a private physician office.
- 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 co-payments.
- Hospital services are processed under hospital benefits and are subject to deductibles and coinsurance amounts.
- Depending on your health insurance plan, you may have greater out-of-pocket expenses when receiving care at a hospital-based outpatient clinic, particularly if you are covered by Medicare or a Medicare Advantage Plan, have insurance with companies with which Wake Forest Baptist does not have a contract (non-contracted private payers), or if you don’t have insurance.
- Laboratory and radiology services are provided by the hospital and are billed by the hospital regardless of the type of insurance.
How this affects patients with private health insurance.
It is important that you ask your health insurance company the following questions:
- Does your health insurance benefit plan covers hospital charges in a hospital-based outpatient clinic?
- How much of the charge is covered?
- How much will be applied to the deductible?
- How much will you owe (coinsurance) after meeting the deductible?
Many private health insurance companies do not require that we follow the same billing rules as Medicare and Medicaid. If you have private health insurance, the hospital component of the physician office visit is billed as part of the physician bill and is processed by the health insurance company under the patient’s physician benefits.
How this affects patients with Medicare, Medicare Advantage or Medicaid
In a hospital-based outpatient clinic, Medicare and Medicaid patients receive two separate bills for services provided in the clinic, one from the doctor and one from the hospital. Adult Medicaid patients are required to pay two co-payments, one for the physician visit and one for the hospital visit. If you are covered by Medicare or Medicare Advantage plans, you are responsible for paying non-physician charges billed by the hospital after meeting your deductible.
How this affects secondary insurance coverage.
Coinsurance and deductibles may be covered by a secondary insurance. Check with your health insurance company for details.
Why the Medicare Secondary Payer (MSP) questionnaire needs 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.
What to do if you have questions or are having difficulty paying for health care services.
Contact our Customer Service Center at 336-716-1663 or visit Patient Financial Services at Wake Forest Baptist Medical Center on the Main Floor, Reynolds Tower.