Wiki Facility and provider Fees

[CMBA4]

Hi all,

Can someone please help me.

The provider I am trying to help with his medicare claims is asking if he can get paid as a provider and bill for facility charges since his practice has there own OR where he performs procedures. Is this OK to bill with commercial insurances and Medicare? Is there a certain way this should be done? Or can this be a red flag and should not be done?

Thank you!

Cmba

 

[inc1961]

We had a plastic surgeon who owns his own ER. We billed physician services on CMS-1500 and facility charges on UB-04. We only billed for Cigna so I can't speak for Medicare.

Our provider was out of network with both Medicare and Cigna.

 

[thomas7331]

Medicare and most other payers will require a provider to be properly credentialed as a free-standing facility (e.g. ASC) in order to bill facility charges. The location where the procedures are performed would need to be licensed in the state where the facility is located and go through the process of being inspected and certified as meeting the criteria to be considered a facility. From what I understand, this is a difficult process because the standards and requirements for a facility are much higher than those for a private physician office, but if that has done, then billing for facility charges should be no problem. But if not, and the provider bills as a facility when they aren't licensed as one, that is definitely a red flag for payers and has a high potential for problems.