Many Wake Forest Baptist Health patient care locations are considered part of the hospital even if they are located miles away from the main hospital campus. These clinics are called hospital-based outpatient clinics. Because they must follow stricter government rules, hospital-based outpatient clinics are more complex and more costly to operate than a private physician office. When you see a physician or receive services in a hospital-based outpatient clinic, you are being treated within the hospital rather than the physician’s office.
How billing is different:
- At a private physician office, all services and expenses are bundled in a single charge.
- At hospital-based outpatient clinics, all services and expenses are separated into two sections: hospital/facility charges (equipment, supplies, pharmacy, labs, x-rays, etc.) and physician/professional charges (examinations, consultations, test/x-ray readings, surgical procedures, etc.)
How this may affect insurance coverage:
- Depending on your health insurance plan, you may or may not have higher out-of-pocket costs when receiving care at a hospital-based outpatient clinic. Any amount you owe will be based on the specific services you receive and your insurance plan benefits.
- Patients are responsible for any co-pays, coinsurance or deductible amounts for both hospital/facility charges and physician/professional services after insurance has paid.
- Medicare or Medicare Advantage coinsurance (out-of-pocket) costs are based on Medicare’s prescribed rates for each of the two charges: hospital/facility and physician/professional. Medicare patients have a higher coinsurance amount for services at a hospital-based facility.
- Medicaid patients pay two co-payments, one for hospital/facility charges and one for physician/professional services.
What if you have private health insurance and/or secondary insurance:
Ask your health insurance company:
- Does your health insurance benefit plan cover hospital/facility charges in a hospital-based outpatient clinic?
- How much of the charge is covered?
- How much will be applied to the deductible?
- How much will you owe out-of-pocket (coinsurance) after meeting the deductible?
Why the Medicare Secondary Payer (MSP) questionnaire needs to be completed:
As a participating Medicare provider, we must screen Medicare patients according to MSP rules. We will ask you the MSP questions at each visit to help us confirm if Medicare or another payer should be the primary insurance to process your claim.
How we inform you about this:
At appointment check-in, we provide a copy of the notice for Patient Coinsurance Responsibility for Hospital-based Outpatient Clinics for you to read. We also ask you to sign to acknowledge that you have received it.
If you have questions or are having difficulty paying for health care services:
Contact our Customer Service Center toll-free at 336-716-3988 or 877-938-7467, Monday through Friday, 8 am - 5 pm, or visit Patient Financial Services located at Wake Forest Baptist Medical Center on the Main Floor of Reynolds Tower.