How do freestanding emergency rooms bill facility fees?

What is a freestanding ER facility fee?

It is the charge for the building, staff, equipment and supplies behind the visit, billed apart from the physician's own fee. The physician group sends a professional claim, and the ER sends the facility claim. The facility fee vs professional fee post shows both claims side by side.

Texas puts that split in front of the patient. Health and Safety Code section 254.155 requires a posted notice that the facility charges rates comparable to a hospital ER, may charge a facility fee, may be out of network, and that a physician may bill separately. The freestanding ER billing guide covers licensing and types of freestanding ER, so this post stays on the claim.

How is the facility fee built, line by line?

Decide the site type first, because the type decides who builds the claim. Then fill the lines in the order below.

1. Confirm the billing entity. A hospital-affiliated freestanding ED bills under the hospital's enrollment. An independent licensed ER bills under its own NPI and tax ID.
2. Get the form and codes in writing. For the hospital-affiliated site, Claims Processing Manual chapter 4 applies: UB-04, bill type 13x. For the independent ER, the contract or provider manual names the form, revenue codes and place of service.
3. Report the visit. ER services go under the 045x revenue code, normally 0450, with the visit level (99281 to 99285, such as 99285) set by the hospital's own internal guidelines. The line date is the date the patient entered the ER.
4. Add each ER procedure on its own line with its own revenue code, separate from the visit line.
5. Add ancillary lines such as lab and imaging under their own revenue codes and dates.
6. Add observation, if the facility offers it, as its own fee. Texas disclosure rules list observation fees apart from facility fees.
7. Add modifier ER on lines from an off-campus provider-based dedicated ED. Chapter 4, section 20.6.18 has required it since January 1, 2019 and says it does not affect payment.

How do the Texas disclosures tie to the claim?

The fee on the patient's disclosure has to be the fee the claim carries. Section 254.156 requires a written statement listing facility and observation fees, in at least 16-point boldface, in English and Spanish, with signature lines. Section 254.157 bars a freestanding ER from holding itself out as a network provider, including by saying it takes or accepts an insurer, unless it is one.

Once a year, and whenever the chargemaster changes, compare three documents line by line: the posted notice, the written disclosure and the fee schedule that drives the claim. A mismatch is a compliance problem and a dispute risk. The Texas rules, with their deadlines for out-of-network disputes, are on the Texas state page.

What does the patient owe on the facility fee?

For an insured emergency visit at a nonparticipating freestanding ER, the patient owes in-network cost sharing, and nothing above it. Under 45 CFR 149.410(a), a nonparticipating emergency facility must not bill or hold the patient liable for emergency services above that cost-sharing requirement.

Under 45 CFR 149.110(b)(3), cost sharing is calculated as if the total charge were the recognized amount. Where no specified state law applies, the recognized amount is the lesser of the qualifying payment amount (QPA) or the billed amount. The plan then pays the facility the out-of-network rate minus the cost-sharing amount, less any initial payment. A facility fee higher than the recognized amount never reaches the patient as a balance.

Medicare is a separate case. CMS has stated that current law does not recognize independent freestanding EDs as certified Medicare providers, so they cannot bill Medicare or Medicaid for services under the federal rules. Whether the NSA covers a given facility is the subject of the next post, do NSA protections apply to freestanding ERs.

What should the patient statement show?

It should show the facility fee lines apart from any physician charge, the plan's payment, and the in-network cost-sharing amount as the only patient balance on an insured emergency visit. A statement that carries the full billed charge as the patient balance on an insured emergency visit conflicts with 45 CFR 149.410(a), and one that folds the physician fee into the facility total hides which claim is which.

• One line per claim line, using the same level names the posted notice uses.
• The plan's allowed or recognized amount and the cost share taken from the explanation of benefits.
• A separate note that the physician group may send its own bill.
• The federal balance billing disclosure. Under 45 CFR 149.430, the disclosure duty covers an emergency department of a hospital and an independent freestanding emergency department.

The plan has 30 calendar days from the date the bill is transmitted to send the initial payment or a notice of denial for emergency services under 45 CFR 149.110(b)(3)(iv). Put that date in the account record, since the open negotiation clock starts when the payment or denial arrives.

What goes wrong with freestanding ER facility claims?

For a facility paid below the right amount, the notice that starts open negotiation is due within 30 business days of the initial payment or denial. The emergency medicine billing page links the code pages for the visit levels.

How does Nucleus Align handle freestanding ER facility billing?

Our hospital and facility billing team prepares institutional (UB-04) claims, validates revenue codes and condition and occurrence codes, and handles payment reconciliation and denial management for inpatient, outpatient and emergency care. Read about hospital and facility billing or book a call.