Hospital Outpatient and Provider Based Billing

Hospital outpatient or provider-based billing is a way that hospitals charge for services provided in practices, clinics or departments that are part of a hospital.

These clinics might be separate locations but still fall under the hospital’s ownership. Valley Health is required to follow specific rules and requirements for outpatient and provider-based billing departments. Not all Valley Health locations are provider-based, but the following are:

• War Surgical Services Clinic
• Shenandoah Behavioral Health Clinic
• Rheumatology of Winchester Medical Center

How does provider-based billing affect the billing process?

When a hospital provides services in its clinics or departments, it follows different billing rules compared to independent practices and clinics. Because care is provided in a location that is considered a department of the hospital, your bill will be separated, and you will receive bills for:

1. The professional or physician fee from Valley Health (this is called a professional fee)
2. Hospital/facility resources and services such as procedures, medications you may have received, etc. (this is called a facility fee.)

Because of these two different charges, you may have two co-pays at the time of your visit. You will also receive two different Medicare Summary Notices—one for the professional fee and one for the facility fee.

Supplemental Insurance:

Patients who have supplemental or secondary insurance may not have any additional out-of-pocket expenses for care. However, patients who do not have secondary or supplemental insurance may have additional out-of-pocket expenses to meet their annual deductible and co-pay. Patients should check with their insurance provider to understand their specific financial responsibility with provider-based billing. There may be cases where patients pay more out of pocket for hospital and provider-based services than they would at another facility.

Why is the practice being converted to a Provider-Based Clinic?

The rising cost of health care and lower reimbursement prompted Valley Health to make this change at certain locations. This Medicare approved provider-based model helps ensure that Valley Health can continue to retain top physicians and staff, and be able to provide the best care possible to our patients.

How will this impact my care

You will still receive the same high-quality care at provider-based clinics, this just changes how Valley Health processes bills related to your visit.

Who can I contact with questions?

If you need help, you may contact the Valley Health Customer Service Team at 1-866-414-4576 Monday - Friday between 8 AM - 4:30 PM with any questions or to make a payment over the phone.