This article discusses provider-based facilities and compliance trends. It notes that hospitals are looking to employ independent physicians as provider-based facilities but must comply with strict regulations. To qualify as provider-based, facilities must meet 15 criteria including integrated licensure, privileges, oversight, and billing. Additional 8 criteria apply to off-campus facilities including hospital ownership and integrated services. Comprehensive monitoring is needed to ensure compliance, as audits check for billing errors that could cause overpayments or loss of provider-based status. While this designation allows higher reimbursement, facilities must carefully consider the significant requirements.

1. 29
Prescription drug
copayment coupons
come under OIG
scrutiny
Hannah Levinson
33
Provider-based
facilities and
compliance
trends
Zorana Vojnovic
47
Compliance
professional 2.0:
Soft skills
needed
Tom Fox
39
OIG 2015
Work Plan, Part 2:
Do fewer projects mean
a sharper focus?
Nathaniel Lacktman
a publication of the health care compliance association www.hcca-info.org
ComplianceTODAY February 2015
From 28 years with the FBI
to solo compliance consultant
an interview with Charles E. Colitre
Compliance and Privacy Officer, Crystal Clinic Orthopaedic Center
See page 18
From 28 years with the FBI
to solo compliance consultant
an interview with Charles E. Colitre
Compliance and Privacy Officer, Crystal Clinic Orthopaedic Center
See page 18
This article, published in Compliance Today, appears here with permission from the Health Care Compliance Association. Call HCCA at 888-580-8373 with reprint requests.

2. 888-580-8373 www.hcca-info.org 33
ComplianceToday February2015
FEATURE
Vojnovic
T
he Office of Inspector General (OIG)
and the Centers for Medicare
Medicaid Services (CMS) lists pro-
vider-based non-compliance as one of its top
concerns. The government is concerned that a
number of hospitals fall short of the govern­
ment-mandated requirements for
provider-based status.1
Independent physicians are look-
ing forward to migrating to hospital
employment and being considered
as provider-based facilities, but they
are not really enthusiastic about the
increased regulatory oversight.
In order to be compliant, providers
must comply with requirements of 42 C.F.R.
413.65(d)2
and all other applicable regulations.
Provider-based status is defined by
relationship between a main provider (e.g.,
hospital) and its departments, remote loca-
tions, satellite facilities, and/or provider-based
facilities.3
Some of them are considered on
campus and others as off campus:
·· On campus are facilities whose physical
locations are immediately adjacent to the
hospital’s main building, and other areas
that are located within 250 yards of the
hospitals’ main building, as well as any
other area determined by CMS to be part
of an on-campus setting.
·· Off campus are the areas not within the
four walls of the main hospital building and
not on campus (i.e., more than 250 yards
from the main hospital building, but within
35 miles of the main hospital campus).
Questions to ask
To satisfy Medicare Addendum C regulation,4
all provider-based facilities (both on and off
campus) should have answers to the following
questions:
1. Do your provider-based facility and the
hospital operate under the same license
(State permitted)?
2. Are the clinical privileges of the hospital
and those of the provider-based facility
integrated?
3. Is the hospital maintaining the same
monitoring and oversight of your
by Zorana Vojnovic, PMP, CRCMP
Provider-based facilities
and compliance trends
»» Many questions need to be asked and answered to determine provider-based status.
»» Hospitals are always looking for a new ways of providing a patient care, but they need to have an understanding about
rules for provider-based facilities.
»» Comprehensive, provider-based monitoring will provide confidence that provider-based facilities are in compliance with
federal regulations.
»» Medicare auditors are checking on place-of-service errors, and mistakes in this area could cause overpayments and jeopardize
provider-based entities status.
»» Billing as a provider-based facility allows higher reimbursement; however, the requirements to be considered provider-based
are significant, and should be carefully considered prior to billing CMS.
Zorana Vojnovic (zvojnovic@mercydesmoines.org) is Associate Corporate
Responsibility and Privacy Officer for Mercy Medical Center in Des Moines, IA.

3. 34 www.hcca-info.org 888-580-8373
ComplianceToday February2015 FEATURE
provider-based facility as for any other
department of the hospital?
4. Is the medical director of your provider-
based facility maintaining a reporting
relationship with the chief medical officer
of the hospital? Is it the same as exists in the
relationship between chief medical officer
and director of other hospital departments?
5. Are medical staff committees or other
professional committees of the hospital
responsible for medical activities (e.g.,
quality assurance, utilization review,
coordination of the services) in your
provider-based facility?
6. Are the medical records for patients treated
in your provider-based facility integrated
into a unified retrieval system of the
hospital?
7. Are the inpatient and outpatient services
integrated with the hospital and do the
patients have full access to all services?
Are they referred to the corresponding
inpatient or outpatient department or
services in the hospital?
8. Is the financial status of your provider-
based facility incorporated and identified
in the hospital financial system? Is the
financial status of the provider-based facility
incorporated and identified in the hospital
trial balance?
9. When patients enter your provider-based
facility or the hospital, are they are aware
that they are entering the main provider’s
facility and are billed accordingly?
10. Does your provider-based facility comply
with EMTALA regulations?
11. Are your physicians complying with
non-discrimination provisions?
12. Does your provider-based facility meet
applicable Medicare Conditions of
Participation health and safety rules?
13. If the provider-based facility patient is
admitted to the hospital as an inpatient
within the 72-hour window, how are
payments treated for the services in the
provider-based facility?
14. Does your provider facility comply with the
terms of the hospital provider agreement
(Medicare/Medicaid)? Do you treat
Medicare patients as hospital outpatients?
15. Does your provider-based facility verify
that it bills the correct site-of-service for
physician services? How are Medicare
patients treated for billing purposes?
Additional questions to ask
for off-campus facilities
1. Is your provider-based facility 100% owned
by the hospital?
2. Do your provider-based facility and the
hospital have the same governing body?
3. Is your provider-based facility operated
under the same organizational documents as
the hospital?
4. Does the hospital have the final
responsibility for administrative decisions,
final approval for contracts with outside
parties, final approval for personnel actions,
and final responsibility for personnel
policies and medical staff appointments?
5. Is your provider-based facility under direct
hospital supervision?
6. Is your provider-based facility under a
management agreement?
7. Are the following services of your provider-
based facility integrated with the hospital:
billing, medical records, human services,
payroll, employee benefits, salary structure,
and purchasing?
8. Does your provider-based facility provide a
written notice to the beneficiaries, before the
services are delivered, of the amount of its
potential financial liability (co-insurance)?
9. Are your provider-based facility staff
employed by the hospital? (Note: This does
not include management staff or staff that
would be paid under the Medicare fee-for-
services schedule).

4. 888-580-8373 www.hcca-info.org 35
ComplianceToday February2015
FEATURE
2015 COMPLIANCE INSTITUTE
®
Preview
SESSION 111 The Easiest Catch:
Don’t Be Another Fish in the Net
Monday, April 20 11:00 am – 12:00 pm
You’ve read the headlines. Unfortunately, the question now is not if your information is going to be accessed or stolen, but when.
In an effort to inform the attendees of current developments in the digital underground — as well as provide realistic advice for cyber protection —
Mark Lanterman will be discussing recent high-profile cyber-crime events, including website breaches impacting retailers, banks and State
agencies. Mark will discuss particularly dangerous types of threats that might affect individuals such as phishing, cyber-stalking, and Wi-Fi attacks.
To hear more, attend HCCA’s 19th
Annual Compliance Institute in Lake Buena Vista, FL!
Visit www.compliance-institute.org for more informatıon or to register.
Mark Lanterman
CEO/Chief Technology Officer,
Computer Forensic Services
Conclusion
Comprehensive, provider-based monitoring will
provide confidence that provider-based facilities
are in compliance with federal regulations.
Medicare auditors are checking on place-of-
service errors, and mistakes in this area could cause
overpayments and jeopardize provider-based status.
Billing as a provider-based facility
allows higher reimbursement, however the
requirements to be considered provider-based
are significant, and should be carefully consid-
ered prior to billing CMS.
1. CMS OIG Work Plan for FY 2015. Available at http://1.usa.gov/113zaLV
2. Federal Register: Requirements for a Determination that a Facility or
an Organization Has Provider-Based Status. October 1, 2011.
Available at http://1.usa.gov/16MIK9b
3. CMS: Medicare Manual: Addendum C: Medicare Provider-Based
Criteria. March 18, 2014. Available at http://bit.ly/1t6JmRb
4. Abbey Abbey Consultants, Inc: Provider-Based Rule
(PBR) Information Toolkit. February 11, 2014. Available at
http://bit.ly/1wCO1Kl
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