FAQs regarding HMSA Akamai Advantage plan changes relating to facility fees
HMSA recently announced changes to the benefits they provide their Medicare plan (Akamai Advantage) members relating to facility fees, effective January 1, 2016. We want to clarify that this is solely an HMSA financial decision. It is not a change in the way that any of our hospitals and clinics operate and bill for services provided.
To cover the costs of care, it is normal for a hospital-based clinic to bill for a “facility fee” in addition to any professional (doctor) fees for the services provided. Although all four of Hawai‘i Pacific Health’s hospitals are listed in HMSA’s announcement, patients affected will mainly be those receiving services at Straub Clinic & Hospital. As a hospital that is part of an integrated system along with doctors and clinics, Straub bills separately for facility and professional fees under Medicare.
The amount patients pay will depend on their insurance. HMSA’s recent announcement states that they are reducing coverage of facility fees for Akamai Advantage members from 100 percent to 80 percent.
Here are answers to some frequently asked questions to assist our patients who may be affected by HMSA’s changes:
Q. What is a facility fee?
A. To cover the costs of care, it is normal for a hospital-based outpatient clinic or location to bill for facility and professional (doctor) fees for the services provided. The fees pay for the infrastructure and staffing that support the clinic and its patient services.
Q. Why do hospital-based clinics charge this fee when stand-alone clinics do not?
A. This is a standard model for large healthcare systems and for facilities that function as departments of hospitals compared to those that are free-standing, such as Straub Medical Center.
Hospitals and their affiliated facilities provide access to critical hospital-based services that are not otherwise available in the community. Hospital facilities also have higher cost structures than other facilities due to the need to have emergency stand-by capacity and higher costs associated with regulatory requirements imposed on them.
See additional information below about provider-based billing as it relates to Straub Medical Center.
Q. How much is the facility fee and what will my out-of-pocket costs be?
A. Based on HMSA’s benefit structure posted on their website, we estimate that the patient portion of the facility fee may be less than $25. We encourage patients to contact HMSA directly to get clarification based on their specific insurance plan.
Q. When is this change effective?
A. HMSA is making this change effective January 1, 2016.
Q. Why is this change being made?
A. Facility fees are not new fees and have always been in place. What has changed is that health insurers are now passing on these costs to their customers. In this particular situation, this is solely an HMSA financial decision. It is not a change in the way that any of our hospitals and clinics operate and bill for services provided.
Hawaii Pacific Health patients with additional questions about billing for outpatient services may call us at 808-522-4013. Customer Service representatives are available Monday-Friday, 9 a.m.-4:30 p.m.
Provider-Based Billing Information for Straub Medical Center
Medicare recognizes the benefit of an integrated system where the hospital and the doctor’s office work together to provide the care and services a patient needs. Straub Medical Center’s King Street clinic and many of the satellite clinics are considered part of the hospital and meet the required criteria to be designated as “provider-based.” “Provider-based” is a special Medicare designation that acknowledges this collaboration by reimbursing both the hospital and the doctor’s office for services rendered during a patient’s visit.
This integration and collaboration offers many benefits to the patient, including better teamwork and improved continuity of care. It also enhances electronic health record capabilities, contributing to patient safety and quality care. Patients benefit as clinic practices are subject to the same rigorous hospital quality standards that are set by and monitored by The Joint Commission, which is recognized nationally as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
Some important points to know about how this impacts Straub Medical Center include:
- Straub has had the “provider-based” designation since 1999.
- Straub’s King Street and satellite clinics are departments of the hospital. For a complete list of all Straub locations, visit our locations page.
- Additional information about provider-based billing is posted on the Straub website under “Understanding Your Bill”. Patients can be directed to this webpage for more information. It also includes contact information if patients would like to speak with customer service representatives for further assistance in understanding their bill.