Facility fee billing update
September 12, 2016
If you received a bill for a "facility fee" from your provider this year, here is an explanation and an update.
What is a facility fee?
A facility fee is charged under a billing practice called "provider-based billing" or "hospital-based billing" allowed under Centers for Medicare and Medicaid Services (CMS) rules that's used by some large integrated delivery systems. What this means is when a member sees a provider whose practice is owned by a hospital who participates in provider-based billing, the provider submits two bills: one for professional services rendered and one for the facility.
Priority Health is paying the facility fee for the rest of this year
In January 2016, as outlined in our plans' Annual Notice of Changes and Evidence of Coverage documents, Priority Health started sharing the cost of the facility fee with our members. We always want to do the right thing for our members, and after getting feedback, our leadership team has since decided to cover that charge in full. For any covered services our Medicare Advantage members have for the remainder of 2016, even with a provider who participates in provider-based billing, members will not be responsible for the facility/clinic fee.