Provider-Based Licensure and Certification

According to CMS regulations, provider-based entities must meet specific criteria for both on-site and off-site departments. In conjunction with the provider-based rules, health care entities need to be cognizant of their own state’s licensure and certification rules. Some states require licensure of each off-site location that wishes to be affiliated with a main provider, while others don’t require any kind of licensure.

You must meet the provider-based rules to bill as provider-based, which means being proactive in meeting the relevant criteria and having information available for CMS review. You can also submit an attestation to CMS to obtain approval that your organization meets provider-based criteria to protect your organization from retroactive review of your provider-based status. We can help you:

  • Prepare financial feasibility studies to determine differences in Medicare and Medicaid or Medi-Cal reimbursement of provider-based versus freestanding entities
  • Review state licensure, Medicare certification, and provider-based criteria against your current operational setup
  • Develop a work plan to help you comply with all provider-based criteria, including organizational issues, signage, billing, charge master, management issues, and proper treatment in the Medicare cost report
  • Set up physician and nonphysician services to be billed appropriately in a provider-based department

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