Provider Based Outpatient Clinics
Prairie Ridge Health Clinic – Columbus is a Provider-based hospital outpatient clinic. If you are covered by insurance your out-of-pocket costs for seeing a physician and receiving services in our provider-based outpatient clinic may be more, compared to the out-of-pocket cost for the same services at Prairie Ridge Health Clinic – Beaver Dam or Marshall (a stand-alone, private office setting, separate from hospitals physical location).
Laboratory and Radiology services are provided by Columbus Community Hospital, Inc. (CCH) are billed by the hospital regardless of the type of insurance.
Below are frequently asked questions (FAQs) related to Provider-based outpatient clinics:
Q: What does ‘Provider-based Outpatient’ mean?
A: Provider-based outpatient clinics are considered part of Columbus Community Hospital. When you see a physician or receive services in a provider-based outpatient clinic, you are being treated within Columbus Community Hospital rather than a physician’s office.
Q: What is different about a provider-based outpatient clinic?
A: 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 provider-based outpatient clinic, physician and Columbus Community Hospital charges are billed separately. For patients with insurance, physician services are processed under the physician clinic benefits which may be subject to patient out-of-pocket responsibilities in the form of co-payments, deductibles and/or coinsurance amounts. Charges for hospital services are processed under the outpatient hospital benefits of the benefit plan and may have additional patient out-of-pocket expenses.
Q: What should I ask my insurance carrier?
A: Making informed healthcare decisions is important. Ask your insurance company if your benefit plan covers facility charges in a provider hospital-based outpatient clinic and how much of the charge is covered. The types of forms that will be sent to your insurance are a UB for hospital charges and a CMS 1500 for the hospital based clinic charges. Ask if any portion of the visit will be applied to your deductible, co-insurance or a co-pay.
Q: Does this apply to patients with private insurance like Anthem, Physicians Plus or Unity?
A: Many private insurance companies do not require that we follow the same billing rules required by Medicare and Medicaid. For patients with private insurance, the facility component of the physician office visit may be billed as part of the physician bill and processed by the insurance company under the patient’s physician benefits. Every insurance company has their own guidelines. Therefore, it is best to contact them to understand your benefits.
Q: What if Medicare patient has secondary insurance coverage?
A: Co-insurance, co-payments and deductibles may be covered by a secondary insurance. Check your benefits with your insurance company for details.
Q: I have Dean Health Plan, will I have a co-pay?
A: Dean Health Plan does not recognize Provider Based clinics and all charges will be billed as physician charges and applied under patient’s physician benefits.