Provider Based Billing

Participating Health Plans

participating health plans

Many of our outpatient locations are extensions of the McLaren Central Michigan hospital using Provider Based Billing.  Commonly asked questions about this type of billing are answered below.

What is Provider Based Billing?

Provider Based Billing, also known as Hospital Based Billing, applies to physician practices that are owned and operated by a hospital.  The physician office is held to the same quality standards and accreditation policies as the main hospital.  The practice is considered an extension of the main hospital campus, and as such there is additional reimbursement allowed under Medicare and Medicaid.

The Center for Medicare and Medicaid Services (CMS) is the federal government agency which administers the rules and requirements, including billing policy, for Provider Based Clinics.

How will Provider Based Billing affect my bill?

When you seek care in a physician practice known as provider or hospital based, keep in mind that the site is an extension of the hospital's main campus.  You will receive two separate billing statements, often referred to as "split billing."  One is for the professional services of the physician (or physician's assistant).  The second is for the hospital portion of your service.  The hospital employs the support staff of the physician practice and owns or leases all of the equipment and supplies.  This component of the bill is how the hospital is reimbursed for those costs. 

Are all patients billed this way?

No.  Provider Based Billing applies to Medicare, Medicare Advantage, Medicaid, and TRICARE.  Other insurances are not billed in this manner, as they have developed policies asking for this type of split bill. However, the charges for like services are the same in all instances.

Will I pay more "out-of-pocket" for services in a Provider Based Billing setting?

Medicare fee schedule is higher under Provider Based Billing, so the coinsurance portion will be slightly higher. The Medicare beneficiary is responsible for the coinsurance amount on each of the split bills.  The coinsurance amounts are determined by Medicare and are based on the services performed

Provider based services, as in any Medicare Part B services, you must satisfy your annual deductible before Medicare or Medicare Advantage pays any portion of the allowed fee schedule for services provided.   Some Medicare patients hold supplemental policies, often known as "Medigap," which covers the additional out-of-pocket costs.

Where can I call for further information?

Please contact McLaren Central Michigan billing office at 989-772-6778.