Fast Facts: Provider-Based Status

What is provider-based status?

• Defined by Centers for Medicare & Medicaid Services (CMS)
• Outpatient clinics are viewed as part of main provider
• Must meet specific criteria
• Applies to both on and off campus facilities
• Allowed to bill facility visit level charge
• Attestation voluntary, not required
• Only considered billing inappropriately if facility does not meet relevant criteria

What is the criteria for all provider-based facilities?

• Integration with main provider

  Financial

  • Financial operations of the facility are fully integrated within the financial system of the main provider, evidenced by shared income and expenses
  • Costs of provider-based facility are reported in the appropriate cost center of main provider
  • Financial status of facility is incorporated and readily identified in the main provider’s trial balance

  Clinical

  • Professional staff of the facility have clinical privileges at the main provider
  • Medical records for patients treated in the facility are integrated into a unified retrieval system or cross-referenced, with main provider
  • Patients treated at the facility have full access to all services of the main provider

  Administrative

  • Facility and main provider are operated under the same license, unless separate State licenses are required
  • Facility medical director maintains a reporting relationship with the main provider at the same frequency, intensity and accountability as other hospital departments
  • Main provider has responsibility for medical staff committees and programs, such as quality assurance and utilization review

• Facility is held out to the public as part of the main provider

• On campus or meets off-campus criteria

What is the additional criteria for off-campus facilities?

• Located within a 35-mile straight line radius of main provider (exceptions for same population or government operation)
• 100% ownership by main provider
• Provider-based facility has same governing body as main provider

• Operated under same operating documents as main provider

  • Common bylaws
  • Subject to operating decisions of governing board

• Main provider has final administrative control

  • Contracts with outside parties
  • Personnel actions and policies
  • Medical staff appointments

What are the requirements for management contracts?

A facility not located on the campus of a main provider, but meeting criteria for off-campus provider based status, must also meet the following criteria if operated under a management contract:

• The main provider employs staff directly involved in the delivery of patient care
• Administrative functions of the facility are integrated with main provider
• Main provider has significant control over facility operations
• The management contract is held by the main provider itself, not a parent organization

Are joint ventures allowed?

Yes, under the following conditions:

• Partially owned by at least one provider
• Located on main campus of a partial owner
• Claim provider-based status to the provider on whose campus they are located
• Meet all other requirements applicable to provider-based facilities