Patients ’ Out-of-Pocket
By Heart Center of North Texas
What ’ s Going On ? Did you get sticker shock after visiting your doctor recently ? Are you surprised by the fees you ’ re being charged to see your doctor , or when you get in-office testing ( called ancillaries ) like EKGs , ultrasounds , or stress tests ? Were you charged for hospital “ facility fees ” or “ clinic fees ” even though you never stepped inside a hospital ? Such hospital facility fees often involve greater dollar amounts than the fees charged by independent physicians . And , as patients bear a greater portion of their health costs , those fees are transferred to the patient . Many patients in Denton County are unexpectedly being billed hospital fees when they visit doctors ’ offices affiliated or owned by local hospitals .
Why Is This Happening ? Why do hospitals and large health systems charge substantially more than independent physician practices , even for the same procedures ? One major reason is facility fees . This is called provider-based or hospital outpatient billing . In this billing model , patients may ultimately receive two fees on their combined patient bill for services provided within a medical office or clinic : one charge represents the facility or hospital charge and one charge represents the professional or physician fee .
When a physician provides a service in a facility that is part of the hospital , the hospital can charge a facility fee . When a physician becomes affiliated with a hospital system or employed by a hospital practice , the hospital can make their office location an extension of the hospital ( even if it ’ s not in the hospital ), allowing the hospital to bill a separate facility or clinic fee for routine office visits and ancillary testing , in addition to the physician ’ s fee . Even if the hospital does not bill a clinic or facility fee to see your doctor , they can still convert certain in-office procedures ( called ancillaries ) to hospital procedures , allowing the hospital to bill at hospital rates on procedures previously billed as office procedures . Some procedures get reimbursed significantly higher at hospital rates than office rates . These controversial charges are routinely tacked on to patients ’ bills not just for services actually provided in hospitals , but also by outpatient care centers and doctors ’ offices simply because they ’ ve been purchased by or aligned with hospital-based health care systems , even if the service was not provided on the hospital campus .
The hospital industry argues facility or clinic fees are meant to cover hospitals for overhead that a freestanding physician ’ s office does not carry and have to be based at least in part on where a medical service is rendered . That means hospitals , which have higher overhead and substantial costs for equipment , technology , and personnel that a freestanding , independent physician ’ s office does not carry , get to collect more money for the same service than at an independent doctor ’ s office . Even for insured patients , this can drive up out-of-pocket expenses such as copays and deductibles . But the reality is , in medical clinics , independent physicians face the exact same overhead challenges –– clinic supplies , staffing , space , and equipment . When hospitals acquire freestanding medical offices , their additional overhead is not on par with that of a hospital –– there are no sterile operating rooms , no fully staffed 24-hour ER or intensive care unit in these offices . There is no expensive high-tech hospital equipment . It is a physician clinic , with physician clinic overhead . In many cases , the staffing at these groups does not change whatsoever .
How Is This Happening ? Since April 2000 , when Medicare clarified its policy in regards to billing by hospitals or hospital-aligned health groups , hospitals have been able to get away with charging patients considerably more than independent physician offices for the same service . Under these federal regulations , health systems are permitted to charge a hospital facility fee for an outpatient service if it ’ s done in a clinic that is “ hospital-based ”–– meaning that the clinic is owned and operated as part of a hospital or health system , regardless of whether the clinic is physically located on the hospital grounds .
The federal government has acknowledged this is a problem and is attempting to stop the practice , but political progress is slow .
Heart and Vascular Services in Denton These same incentives have now caught up to us in Denton . In the past year , an overwhelming majority of independent cardiologists have been employed by local hospital networks .
According to a 2013 MedPac report , the fees for office visits , echocardiograms ( EKGs ) and nuclear cardiology tests at hospital-owned practices are dramatically higher than at independent ones . We have seen patients who have been told their charge will be roughly 10x what we charge a patient for an ultrasound . And Medicare reimburses the hospital almost three times for a nuclear stress test than they do at an independent physician practice such as ours . There are only five independent cardiologists left in Denton , and ours is the only practice that offers on-site nuclear stress testing and ultrasound imaging .
32 DENTON COUNTY Living Well Magazine | NOVEMBER / DECEMBER 2016
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