How to Know How Much a Hospital Actually Charges

It is common knowledge that it is difficult to determine how much you will pay for an operation or procedure before it happens. First, hospitals do not charge everyone the same rate; they discuss prices with insurers and often try to keep the exact numbers secret. The good news, however, is that federal law now requires hospitals to publish their price lists. The bad news is that lists are often hard to find and even harder to read.

This topic came up when we recently spoke with investigative journalist Dan Weissman about the upgrade , and he told us that the law did not necessarily make the buying process easier, although this may vary depending on your hospital and the state you live in.

The New York Times has now published its own guide to finding local hospital price lists. This is a multi-step process and you may fail because many hospitals do not comply with the law or choose to do it in a way that is difficult to navigate. But there is hope. Here’s what they recommend:

  1. Know your exact health care plan . For example, it is not enough to know that you have United. Be specific. Do you have an HMO or PPO? Did you get it through your employer or did you buy it from the ACA marketplace?
  2. Google “price transparency” and the name of the hospital . From there, search the hospital’s website for anything that says “chargemaster,” “standard rate list,” “comprehensive machine-readable file,” or “negotiated price list.”
  3. Look for CPT codes , 5-digit numbers that represent specific procedures or services. You may need to call the hospital to find out which CPT codes will be billed for the procedure you are getting.
  4. Look for prices . There might be columns for the base rate, different insurers, and the price they charge if you pay in cash.

Unfortunately, there is no standard file format that hospitals should use, so what you may find may differ. And some have not posted theirs at all.

Does it work in practice?

With all the warnings, I did not have high hopes, but took the procedure for a test run.

I tried the steps above for the hospital closest to me (on the UPMC network) and an initial Google result led me to a price estimator. I had to click the screen to realize that the prices shown are approximate and not guaranteed, and even then I was unable to find some common procedures such as knee replacement surgery. This is not the webpage I was looking for.

So I went back and entered “standard payments” into my Google search, and this time I ended up on a different pricing page. I even found a “COMMON PRIMARY KNEE” there for $ 5,109. But there was no CPT code, and it did not differentiate by insurance plan. The hospital page states that this is a “base fee” and that the amount you end up paying after getting covered may differ. They also say :

Because your plan’s payments determine your out-of-pocket costs and your payments for services are based on negotiated rates, the hospital CDM standard payments file is not a useful tool for determining the out-of-pocket costs you will pay for your services. healthcare.

Instead, they recommend that you use a rating tool or call a phone number to get a rating. This score, by the way, may be higher or lower than what you actually get.

The New York Times recommends filing a complaint here if your hospital does not comply with the law, but it is difficult to know if this is the case. If I am a patient or caregiver trying to set a price for treatment, should I also be a lawyer and medical billing expert?

Or, for that matter, am I supposed to be a literal machine? On UPMC’s page, after all companies have stated that its chief of charges is a “useless tool,” provides a machine-readable file that they say does indeed include negotiated prices and that each procedure costs money. Using the JSON reader , I can see it well enough to hit Ctrl-F and poke around, but I don’t fully understand everything there is. I think I see a cash charge rate of $ 3,856 for a complete knee replacement and the negotiated price is only $ 395.24, but I’m really not sure if I’m getting that right.

There is little hope for the future: with all these incomprehensible but machine-readable price lists, third-party companies will probably show up to read them for you. “Turquoise health” is what NYT is celebrating. In my area, the local newspaper has a local hospital tool that is a little awkward to use and only shows 70 common procedures, but the results are instructive: In one hospital, insurance companies pay $ 99 to $ 362 for mammograms with a list price of $ 713. Medicare pays $ 66 for the same procedure; people who pay in cash are charged $ 570.

This price mismatch is why price transparency is so important, but it makes it infuriating to try to navigate the data when you’re just trying to be responsible for your money and your health. We hope that if you look at the price lists of your local hospitals, you will find something more informative than me.

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