Provider-Based Billing

Provider-Based Billing

Lima Memorial Health System’s (LMHS) physician offices are provider-based clinics. Receiving care from our providers at our clinics will result in a professional or physician charge and a facility charge for services and / or procedures. This will be reflected on statements you receive for provided services.

Patients are advised to review their insurance benefits or contact their insurance provider to determine what their policy will cover and identify any out-of-pocket expenses. 

If you have further questions regarding provider-based billing, please reach out to our Patient Accounts representatives at 567-242-0460.

FAQs

What does provider-based mean?

Provider-based refers to the billing process for services provided in a hospital outpatient clinic or location. It means that hospitals have met specific Medicare regulations to have their outpatient physician office and clinics classified as provider based. Most large hospital systems are classified as provider based by Medicare, which results in uniform billing.

Why provider-based billing? 

Provider-based billing is used across the U.S. by many healthcare systems and improves the quality of care for patients. Patients benefit because all hospital outpatient departments are subject to strict quality standards and are monitored by The Joint Commission. The Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards. 

Does provider-based billing apply to me if I’m not covered by Medicare?

Yes, provider-based billing applies to all patients, not just those covered by Medicare.

How does this affect my bill?

With the provider-based billing model you may receive two (2) bills; one represents the facility or hospital charge, and one represents the professional or physician charge. The total charges are intended to equal the one charge that would be incurred at a non-provider-based clinic for an office visit.

Does this mean I will pay more for services?

Depending on your insurance coverage, it is possible benefits may differ for certain services and procedures at our provider-based clinics. We recommend you review your insurance benefits or contact your insurance provider to determine what your policy will pay and what out-of-pocket expenses you may incur.

Does this affect my co-pays, out-of-pocket expenses or deductibles?

Depending on your specific insurance benefits, additional out-of-pocket expenses may be incurred by provider-based billing.

My insurance policy states that I will now owe my deductible or a co-insurance if my laboratory and / or radiology tests are done in the physician’s office. Does that apply?

Your laboratory tests are processed as a hospital outpatient test at LMHS, so your insurance company may apply your outpatient deductible and co-insurance. Check with your insurance carrier or policy manual to see how your deductible and co-insurance will be applied. 

Where can I call with my questions or concerns?

LMHS understands that navigating healthcare may be difficult; if patients have questions about their bills, payment options, payment plans, financial assistance or insurance, they can call our Patient Accounts team at 567-242-0460 Monday – Friday during the hours of 8 am – 5 p.m., and a representative will be available to answer your call.

What if I have Medicare or Medicaid as a secondary insurance coverage?

Coinsurance and deductibles may be covered by a secondary insurance. Check your benefits or contact your insurance company for details. 

How does provider-based billing affect me if I have Medicare?

The hospital services, physician and clinical professional services will be charged to Medicare. If you have secondary or supplemental insurance, we will submit any balance to that insurance plan. If your secondary insurance does not cover the balance or if you do not have secondary or supplemental insurance, the balance will be billed to you.

How does provider-based billing affect me if I am not covered by Medicare?

Your insurance company may handle provider-based charges different from Medicare.  Some insurance companies may apply these charges to your annual deductible and coinsurance. To find out what will be covered, contact your insurance company.

If I am unable to make a full payment immediately, can I set up a payment plan?

Yes. Please contact our Patient Accounts team at 567-242-0460. We would be happy to assist you.

What can I do if I am having difficulty paying for healthcare services?

LMHS understands patients may have concerns regarding the cost of healthcare and treatments. We’ve expanded our financial assistance program to help offset the out-of-pocket expenses patients may incur. Patients can apply for financial assistance by completing applications available in our physician offices, Lima Memorial Hospital or on our hospital website at www.limamemorial.org.  

Our financial assistance program is available for medically necessary care if you are a resident in our hospital’s service area. Our hospital service area is defined as the following counties: Allen, Auglaize, Hancock, Hardin, Mercer, Logan, Putman, Paulding, Shelby and Van Wert. Financial assistance is based on patient’s household size and income. 

Our Patient Accounts team is available to help provide information regarding our financial assistance program in person at our main hospital or by phone at 567-242-0460.