Provider-Based Billing

Prairie Lakes Health Care System consists of clinics and a hospital that serve the health care needs of people in communities in Northeast South Dakota and Northwest Minnesota.

For patients who have Medicare insurance, Prairie Lakes Healthcare System bills services as provider-based billing, sometimes called hospital-based billing.

Frequently Asked Questions:

What is provider-based billing?
Provider-based billing is a type of billing for services provided in a clinic or department considered part of the hospital. This often is the case with large health care systems. Clinics located off the main hospital campus may be considered part of the hospital. Even though you’re seeing your regular physician in a clinic setting and not actually hospitalized, your visit is billed under the hospital rather than the physician’s office.

What is different? Will I pay more for services?
In many cases, you will begin seeing a statement with charges split apart for each visit. One charge will be a professional fee (clinic charge), and the other will be a technical fee (hospital charge). The combined total charge is the same, but the components are split.

Depending on your specific insurance coverage, it is possible that some benefits will differ for these services and procedures. Some patients may have to pay a higher cost because a portion of the billed service is being charged as a hospital charge. The increase in cost is a result of the health plan’s coinsurance and deductible, so not an increase in actual fees. Patients with a supplement plan are not likely to see much change.

Will my appointment be different?
Your clinical care will not change. You will continue to see your regular doctor and health care team, and continue to receive outstanding, quality care. Scheduling appointments and tests remains the same.

Are all patients being billed this way?
No. The requirement for breaking out charges for each office visit is set by the Centers for Medicare and Medicaid Services (CMS). Thus, only patients with Medicare insurance are billed using provider-based billing. At this time, commercial insurance companies do not require this breakout.

What if I have questions?
Please review your insurance benefits or contact your specific insurance provider to determine any changes to what your policy will cover.