Top 10 questions regarding provider-based clinics and provider-based billing

Provider-based clinics continue to be scrutinized, so it’s important for facilities to help ensure that their clinics are meeting Centers for Medicare & Medicaid Services (CMS) criteria and following provider-based billing guidelines.

1. What is a provider-based clinic?

“Provider-based” refers to a Medicare billing status and process for physician professional services that are provided in a hospital outpatient clinic. A provider-based clinic must meet Medicare provider-based regulations and billing requirements.

2. Must a provider-based clinic be on the main campus of the provider?

No, a provider-based clinic may be an on-campus location within 250 yards of the main buildings (the 250-yard rule for hospital-based clinics) or located off campus. The CMS definition of “campus” requires the on-campus outpatient hospital clinic to be within 250 yards of the main buildings.

3. Are there different provider-based billing rules for an off-campus location?

Yes, additional provisions apply to off-campus locations under the CMS provider-based billing guidelines. Some additional hospital outpatient department requirements are:

• The clinic must be within 35 miles of the main provider unless the 75/75 test is met. This does not apply to a rural health clinic (RHC) and will not impact RHC reimbursement rates under the prospective payment system.
• A critical access hospital (CAH) provider-based clinic should not be within 35 miles of another hospital or provider-based department of a hospital since this would put the hospital’s CAH status in jeopardy.

4. What is an attestation?

An attestation is a signed statement by the facility-based provider affirming that it meets all required provider-based status criteria.

5. Is a provider-based clinic required to file an attestation?

No, meeting the provider-based status criteria (see the complete list in 42 CFR 413.65) is required; however, the attestation and review process is voluntary.

6. Since it is not required, what is the benefit of submitting an attestation?

By submitting an attestation, a provider will obtain a determination of provider-based status from CMS. This determination will state whether the facility meets the relevant provider-based requirements for on-campus or off-campus locations, and upon approval, the facility will be designated as having provider-based status.

If an attestation for formal review is submitted by the facility, it increases the likelihood that the facility is properly adhering to the provider-based status criteria. In addition, if CMS subsequently discovers the facility has been PBB billing as provider-based and an attestation has been made and approved but does not meet the provider-based billing rules, then CMS would not recover all past payments for cost report periods subject to reopening.

Instead, it would limit such recoupment back to the date the complete request for a provider-based status determination was submitted. At the time CMS determines a facility that submitted a complete attestation is actually not provider-based, payment would continue for up to six months, but only at a reduced rate as described at 413.65(j)(5). Under 413.65(l)(1), treatment of a facility as provider-based would cease only with the date CMS determines the facility no longer qualifies for provider-based status if the reason the provider-based criteria are not met is a material change in the provider-facility relationship that was properly reported to CMS.

If a facility elects to bill as provider-based yet forgoes the attestation and review process and is later found not to be in compliance with the regulatory requirements, CMS may recover the difference between the amounts reimbursed as provider-based and the amounts that would have been reimbursed as a free-standing facility. This recovery may be made for all cost reporting periods subject to reopening.

7. How does a provider-based clinic submit an attestation?

There is not an official CMS form for an attestation and evaluation of provider-based status. Guidance for the content of the attestation can be found in Program Memorandum A-03-030, published April 18, 2003. Some Medicare MACs and CMS regional offices do have a preferred format. It is best to check the MAC’s website for information and contact the person listed for additional information.

The attestation should be filed, along with all support, with the Medicare A/B MAC, and a copy should be sent to the CMS regional office for the state in which the facility is located.

8. Can a clinic bill as provider-based prior to receiving the determination of provider-based status?

Yes. A determination of provider-based status can take up to six months for CMS to process. Since the attestation is voluntary, if the facility meets all of the provider-based criteria, it does not need to wait to begin provider-based billing.

9. What if the clinic has been billing as provider-based but never filed an attestation? Can it still file one?

Yes. An attestation can be filed at any time to receive the determination of provider-based status from CMS. If the clinic operates as provider-based and is doing PBB billing, it is advisable to file an attestation and have the clinic designated provider-based.

10. What other items should be considered when seeking provider-based status?

How Wipfli can help

Wipfli associates understand the massive innovation and demanding regulations sweeping through the healthcare industry, and we’re ready to help you navigate them. Contact us or learn more about our services by visiting our rural health solutions page.