Question Provider based CMS guidance on reimbursment

nclawson

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My organization is considering eliminating our provider based billing practices. Is there documentation showing if the reimbursement would increase on the professional side if this occurred? There is the thought process that by discontinuing the technical facility separate billing and removing ourselves from being provider based the office professional would increase to an extent. I cannot find specific documentation on that.
 

SharonCollachi

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Can you give us more information of your current setup? Are you billing for both facility and provider?

Procedures done in the office pay more to the provider than those same procedures done in a facility. However, the combined total (facility + provider) is more when the procedures are done in a facility.

For example, a spinal injection done in an ASC may pay $250 to the provider and $2500 to the facility (numbers are just for demonstration and are not real-world numbers). That same injection done in the office may pay $500 to the provider, and there is no facility fee. So if your providers own the facility or have a stake in the facility, their overall reimbursement is more if they use the facility.
 

thomas7331

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My organization is considering eliminating our provider based billing practices. Is there documentation showing if the reimbursement would increase on the professional side if this occurred? There is the thought process that by discontinuing the technical facility separate billing and removing ourselves from being provider based the office professional would increase to an extent. I cannot find specific documentation on that.
As a general rule, Sharon is correct above in saying that the combined reimbursement of the facility bill plus the professional claim will typically exceed the reimbursement that you'd expect to see in billing a single global professional claim for the entire amount.

But exactly your providers' reimbursement would be affected by this change is a really difficult question to answer and there isn't any 'documentation' that's going to tell you that. Part of the problem is that if you are billing as provider based, you are being reimbursed on the facility side under a prospective payment system (OPPS) which reimburses based on the estimated average facility costs of groups of similar service in similar locations using historical data, and on the professional side under a fee-for-service system, with set rates for each service rendered based on amount of work, practice expense and malpractice costs for that given service. There is no direct translation of reimbursement from one system to another and you'd need to do financial analysis of the different types of services you are billing, taking into account your payer contracts and payer mix of your patient population, to be able to determine how the change would impact your practice. Depending on the size of your practice, that could be a big undertaking - it's something for which you'd might want to consider hiring a consultant.

In addition, I'd just point out that this has all been complicated by the fact that the reductions that CMS has imposed on non-excepted off-campus provider based facilities over the past couple of years are currently being challenged in court, so there's a big unknown variable here as to what will be the actual final impact for these locations.
 
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