Provider Based Billing
Mayo Clinic Health System consists of clinics, hospitals and other facilities that serve the health care needs of people in communities in Iowa, Minnesota and Wisconsin. The community-based providers, paired with the resources and expertise of Mayo Clinic, enable patients in the region to receive the highest-quality health care close to home.
Thank you for choosing to receive your care with us. We have made some changes to our billing practices that we want to make you aware of.
For our patients who have Medicare and Medicare Advantage insurance, Mayo Clinic Health System bills some services provided as provider-based billing, sometimes called hospital-based billing.
Review these frequently asked questions to help you understand this change:
What is provider-based billing?
Provider-based billing is a type of billing for services provided in a clinic or department considered part of the hospital. This often is the case with large health care systems. Clinics located several miles away from the main hospital campus may be considered part of the hospital. Even though you’re seeing your regular physician in a clinic setting and not actually hospitalized, your visit is billed under the hospital rather than the physician’s office.
What Mayo Clinic Health System locations are billed as provider-based billing?
Provider-based billing affects services provided by Mayo Clinic Health System – Franciscan Healthcare in these locations: La Crosse (most services offered in the hospital and clinic buildings), Onalaska clinic, Holmen clinic and Caledonia clinic.
What is different? Will I pay more for services?
In many cases, you will begin seeing a statement with charges split apart for each visit. One charge will be a professional fee (clinic charge), and the other will be a technical fee (hospital charge). The combined total charge is the same, but the components are split.
Depending on your specific insurance coverage, it is possible that some benefits will differ for these services and procedures. Some patients may have to pay a higher cost because a portion of the billed service is being charged as a hospital charge. The increase in cost is a result of the health plan’s coinsurance and deductible, so not an increase in actual fees. People with a supplement plan are not likely to see much change.
Why make the change?
This is the national model of practice for large health care networks where the hospital owns space and employs support staff who assist with patient care. It has been adopted by many medical centers locally and nationally. This benefits patients as all departments of the hospital are subject to strict quality standards and are monitored by The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 17,000 health care organizations and programs in the U.S. Medicare and Medicaid have distinct payment programs for provider-based billing and require that we make it clear to the public which practices are part of the hospital.
Will my appointment be different?
Your clinical care will not change. You will continue to see your regular doctor and health care team, and continue to receive excellent-quality care. Scheduling appointments and tests will be handled as they have been in the past. At every visit, Medicare patients will be asked to complete an MSP questionnaire containing 10 to 15 questions. We recognize this may feel repetitive, but it is a government requirement.
Are all patients being billed this way?
No. The requirement for breaking out charges for each office visit was set by the Centers of Medicare and Medicaid. Thus, only patients with Medicare, Medicare Advantage and Tricare insurance are billed using provider-based billing. At this time, commercial insurance companies do not require this breakout.
What if I have questions?
We ask you to review your insurance benefits or contact your insurance provider to determine any changes to what your policy will cover. In addition, we have trained staff who can help answer your questions. Call 1-844-217-9591.
What should I ask my insurance carrier?
Making informed health care 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 insurance.
What can I do if I am having difficulty paying for health care services?
We offer financial assistance to help qualifying patients. Information is available by calling Customer Service at 1-844-217-9591. In addition, we can assist with other county, state or national programs for which you may be eligible.