If you are a work comp payer, you don’t have to pay those ridiculous facility fees when care is delivered outside the hospital – at least not in Pennsylvania.
That’s the decision rendered by the Pennsylvania Bureau of Workers’ Compensation in a case dating back to 2017. The case arose when a hospital (which I promised not to identify) tried to get reimbursed for care delivered by an affiliated provider, which was NOT “located within XXX hospital”.
The hospital, a “Part A provider and billing entity” didn’t provide the billed services, rather a
“part B provider whose clinic [was] not located with[in] XXX hospital performed, billed, and was reimbursed for services. XXX hospital is not entitled to payment as XXX hospital provided no medical services…”
The actual provider – a “part B provider” affiliate of XXX hospital, delivered the services, submitted a bill and supporting documentation, and was reimbursed.
The hospital also submitted a bill along with documentation that the treating provider had a professional services agreement (PSA) in place with the hospital.
Notably, the PSA “designates that all care and treatment is rendered by [the affiliate’s] personnel, therefore the payer’s attorney questioned exactly what XXX hospital was “providing.”
There’s a LOT more to this; location codes, provider details, Medicare regulations, bill types and the like are all important. The knowledge level required to correctly reimburse and successfully uphold a denial of payment for facility fees in PA is quite impressive; the entity providing that expertise has a wealth of experience and expertise in the Keystone State.
The cost reduction is equally impressive .
What does this mean for you?
- If you are paying facility fees for care delivered outside of a hospital (Part A) provider, you better get your act together.
- Expertise is way more important than price or throughput.