Establishing Provider-Based Clinics – Advanced Issues

Event Information
Product Format
Prerecorded Event
90 minutes
Product Description

A Comprehensive Review of Hospital-Based Clinics and The Complexities Around Them


Why do hospitals establish provider-based clinics? Do you know what advantages physicians have for being in a provider-based clinic? Why are there ambiguities in the provider-based rule (PBR)? Do you have to meet each and every criterion in order to establish provider-based status, and which required criteria present special problems?

Join expert speaker Duane C. Abbey, Ph.D. in this informative session to review the Provider Based Rule (PBR), and understand the difference between freestanding and provider-based clinics. This 90-minute session will shed light on the economic advantages of provider-based clinics, review the special requirements for provider-based clinics, and appreciate special compliance concerns associated with provider-based status.

Additionally, Dr. Abbey will also answer the following questions:

  • When is CMS interested in making a determination that an operation is provider-based?
  • What CMS-855 enrollment forms must be completed relative to provider-based clinics?
  • How do the physician supervision requirements affect provider-based status?
  • What special coding and billing requirements are required for provider-based clinics?
  • What if we are outside the 35-mile default limit?
  • What if we have a facility in which part is provider-based and part is freestanding?
  • What if we have space that is used jointly by both the hospital and other providers? What kind of signage is really necessary?
  • How do we report changes in provider-based operations? Should we routinely ask for determinations from out MAC?
  • How do we go about auditing our provider-based operations?
  • Are there differences for provider-based operation in the hospital vs. on-campus vs. off-campus?

Session Objectives:

  • Review of coding and billing issues for provider-based clinics.
  • Know how to qualify clinics that are outside the 35-mile default limit.
  • Insights on signage and proper identification for provider-based operations.
  • Review of complicated issues such as joint use of space and time-share space utilization.
  • Understand provider-based reporting requirements and the CMS-855 forms.
  • Learn about the application of the physician supervision requirement for outpatient services.
  • Discuss operation issues such as setting fees, patient relations and medical staff organizational structuring.
  • Review on-going ambiguities in the Provider-Based Rule affecting provider-based operations.
  • Research case studies involving special issues in the establishment of provider-based clinics.

Session Agenda:

  • Review of the Provider-Based Rule (PBR)
    • Development of the PBR
    • 42 CFR §413.65
    • Review of Definitions
  • Economic Advantages of Provider-Based Status
    • Clinics
    • Clinical Services
    • Costs for Provider-Based Status
    • Recognizing Provider-Based Clinical Services
  • Establishing Provider-Based Clinics
    • Meeting the PBR Requirements
    • Coding and Billing for Provider-Based Clinics
    • Physician Supervision Requirements
    • CMS 855 Forms
      • CMS-855-B
      • CMS-855-A
      • CMS-855-I
  • Special Issues and Sensitivities
    • Split-Billing
      • 1500 Claim Form Requirements
      • UB-04 Claim Form Requirements
    • Holding-Out to the Public – Proper Signage
    • Split-Use Facilities
    • Time-Share Use of Facilities
    • Cost Reporting Issues
    • Qualifying Clinics that Are Outside the 35-Mile Default
    • Requesting Determinations and Filing Attestations
    • 3-Day Payment Window Issues – Freestanding vs. Provider-Based
    • Affiliated Hospitals and Remote Campuses
    • Related Laboratory and Radiology Issues
  • Case Studies
  • Sources for Further Information

Who should attend

Chargemaster personnel, compliance personnel, claims transaction personnel, coding personnel, financial analysts, operating officers, clinic administrators and managers, and all personnel involved with provider-based clinics and/or clinical operations, including nursing staff and interested physicians/practitioners.

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About Our Speaker

Duane Abbey Hospital Coding & Compliance Expert

 Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. He performs various types of financial analysis involving business structuring, organizational development, enrolment and other financially related concerns of organizations....   More Info
More Events By The Speaker

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