As more hospital systems evolve into integrated medical systems, which typically include physician medical practices, some organizations are billing for outpatient facility fees in addition to the historical professional fees associated with the medical provider’s services. Professional fees include coverage of the medical office’s facility costs, so the additional outpatient facility fee represents a duplicate charge.
A Real World Example
In a recent audit, Healthcare Horizons’ personnel noted multiple instances of both professional fees billed and outpatient facility claims submitted by a major medical center for patient vaccinations. Our client’s third-party administrator (TPA) initially insisted that paying both types of claims did not constitute duplicate payments. However, the patient’s name, vaccine type and quantity, physical location and date of service were all identical. When we advised the TPA that a facility component was already included in the professional fee, the TPA still contended that there was no duplication of fees charged. However, when client personnel informed the TPA that it was obviously duplicate billing for the same vaccinations, the TPA finally acknowledged the issue and credited our client for the overcharges.
Diligence Should Also be Duplicated
Healthcare Horizons continues to monitor this growing trend and helps our clients quantify and resolve related overcharges. This is another example of the ever-growing need for self-insured employers to have 100% comprehensive audits performed on medical claims payments.
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