What is a standard pricing methodology for hospitalists who provide both inpatient and outpatient services? I am most familiar with ambulatory payment classifications (APCs) and facility pricing. Is there an accepted physician fee schedule methodology that you are aware of?
Answer 1: Hospitalists are physician providers and their payment is for professional services and would be best billed on a Centers for Medicare & Medicaid Services (CMS) 1500 claim form. The payments are based upon the fee schedules that are established and negotiated with the payers (excluding CMS and other government payers). The APC and other facility methodologies are for hospital providers. I would recommend reaching out to an expert consultant or others to develop a plan on how to bill, establish charges, and negotiate contracted rates for these services.
This question was answered by: Matt Levsen, CPA, MBA, FHFMA, associate CFO, University of Missouri Health Care, and a member of HFMA’s Show Me State of Missouri Chapter.
Answer 2: Traditionally, hospitalist services are billed on the CMS-1500 form and paid at physician fee schedules. Currently, our system employs hospitalists through one of our physician companies, not directly through our hospital. When we previously employed physicians directly through our hospital, trying to get 1500s through our hospital-focused central business office was a challenge from an IT perspective. This arrangement also typically creates challenges on the payer side relative to having the same tax-id number on the 1500 form and the facility’s UB-04 form.
This question was answered by: Craig Ganger, director, managed care & decision support, Premier Health, and a member of HFMA’s Southwestern Ohio Chapter.
Answer 3: In general, hospitalists are paid based on the CMS professional services at a percentage that reflects the current physician rates in your area. They are billed and paid separately from the facility services.
This question was answered by: Michele Marcum, CHFP, director of contracting, Humana, Inc., and a member of HFMA’s Idaho Chapter.
Answer 4: I agree with the above responses. I would add that you can buy databases showing typical physician charges for your geographic area from various companies. Basically, we just make sure our charges are a bit higher than our best negotiated rate.
This question was answered by: Ruth Lande, senior vice president, patient care, Memorial Sloan-Kettering Cancer Center, and a member of HFMA’s Metropolitan New York Chapter.
Answer 5: It is important to make sure the coding for hospitalist services is done correctly. The right level of care for evaluation and management services must be identified, coded, and billed. Additional services that are beyond evaluation and management must be identified, coded, and billed as well.
This question was answered by: Robert J. Ellertsen, FHFMA, former hospital CFO with more than 35 years experience in healthcare finance, and a member of HFMA’s Massachusetts-Rhode Island Chapter.
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