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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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
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