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Top 10 questions regarding provider-based clinics

Feb 03, 2019

Provider-based clinics are under more scrutiny than ever before, so it is important for facilities to ensure their clinics are meeting Centers for Medicare & Medicaid Services (CMS) criteria.

1. What is a provider-based clinic?

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

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

No, a provider-based clinic may be on the same campus as the main provider or located off campus. The CMS definition of campus requires the clinic to be within 250 yards of the main buildings.

3. Are there different rules for a provider-based clinic not on the main campus?

Yes, additional provisions apply to off-campus locations. Some additional requirements are:

  • The clinic must be within 35 miles of the main provider unless the 75/75 test is met (does not apply to a rural health clinic (RHC)).
  • 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.
  • The hospital must provide written notice to all Medicare patients, before delivery of services, of the amount of the patient’s potential financial liability.

4. What is an attestation?

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

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

No, meeting the provider-based 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 provider-based.

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 criteria. In addition, if CMS subsequently discovers the facility has been billing as provider-based and an attestation has been made and approved but does not meet the provider-based rules, then CMS would not recover all past payment for cost report periods subject to reopening.

Instead, it would limit such recoupment back to the date the complete request for a provider-based 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 6 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. 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. Must a new attestation be filed when converting a provider-based clinic to a provider-based rural health clinic?

Yes. A new Medicare provider number is issued when a clinic becomes an RHC. It is necessary to get a CMS determination for the RHC to be provider-based to the hospital, at which time a provider-based RHC number will be issued.

9. Can a clinic bill as provider-based prior to receiving the determination?

Yes. A determination can take up to 6 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 billing as provider-based.

10. What if the clinic has been billing 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 from CMS. If the clinic operates as provider-based and is billing as provider-based, it is advisable to file an attestation and have the clinic designated provider-based.

How Wipfli can help

Our associates understand the massive innovation and demanding regulations sweeping through the healthcare industry. Learn more about our solutions on our web page.

Or read more CMS-related articles:

Understanding CMS emergency preparedness rules

How to comply with CMS emergency preparedness rules

Preparing for your next compliance exam


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Wipfli Editorial Team