Flat Rate Pay for Clinic Visits


December 12, 2013


A private practice client recently received an email news alert with the following headline (“Medicare to pay flat rate for clinic visits”) and asked if this applied to the physicians in their practice when they were on call at the hospital.


In late summer, CMS announced that hospital payments for hospital provider based clinics were being consolidated from the current five levels of service to three levels for the hospital (facility side of the billing system). This does not affect physician Part B billing. Provider Based clinics submit fee to Medicare for both the facility and the physician service. The new CMS outpatient clinic facility payment rate for provider based clinics will be paid in 2014 on the flat rate with only 3 associated payments for the current levels of service (e.g. five levels of new patient visits, five levels of established patient visits).

CMS reimburses non provider based physicians on RVUs (Facility and Non Facility) dependent on the place of service. A physician providing services in a non-provider based clinic (where the hospital and physician both submit services) will continue to be paid according to the Non Facility RVUs for the specific level of service (e.g. 99201, 99202, 99203, 99204, 99205) in their practice. The same service provided by the same physician in a Facility setting is paid according to the Facility RVUs.

Many questions have been raised by confusing headlines such as this. KZA appreciates clients reaching out to such ominous and confusing story leads. Remember, the flat rate for clinic visits addressed in this headline applies to hospitals only and does not affect physician part B billing or payments.