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It is notoriously difficult to figure out how much you will pay for an operation or procedure before it happens. For one thing, hospitals don’t charge everyone the same fees; they negotiate prices with insurers and often try to keep the exact numbers a secret. But there is good news: Federal law now requires hospitals to publish their price lists. There’s bad news too: the lists are often difficult to find and even harder to read.
This topic came up when we spoke to investigative journalist Dan Weissman about the upgrade recently, and he told us the law hasn’t necessarily made it easier to poke around – although that may depend on your hospital and the state you live in.
Now the New York Times has published its own guide on how to find your local hospitals’ price lists. It’s a multi-step process and you may not be successful as many hospitals have failed to comply with the law or have chosen a way that is difficult to navigate. But there is hope. Here’s what they recommend:
- Know your exact health plan. It is not enough to know that you have United, for example. Be specific. Do you have an HMO or PPO? Did you get it through an employer or bought it from an ACA marketplace?
- Google “price transparency” and the name of the hospital. From there, look for something on the hospital website that says “chargemaster” or “standard charge list” or “comprehensive machine-readable file” or “negotiated price list”.
- Look for CPT codes, 5-digit numbers that stand for certain procedures or services. You may need to call the hospital and ask what CPT codes will be billed for the procedure you will be given.
- Search prices. There may be columns for a base rate, different insurers, and the price they charge when paying for cash.
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Slim and practical
Great housewarming gift.
Unfortunately, there is no standard file format that hospitals must use. Hence, what you find may vary. And some didn’t post theirs at all.
Does it work in practice?
With all the warnings, I wasn’t getting high hopes, but I took the procedure for a test run.
I tried using the steps above for a local hospital (on the UPMC network) and the first google result led me to a price estimator. I had to click through a screen and acknowledge that the prices quoted were an estimate, not a guarantee, and even then I couldn’t find some common procedures like knee replacement surgery. This is not the website I was looking for.
So I went back and put “standard charges” in my google search and this time I got to a different page of prices. I even found “TOTAL KNEE PRIMARY” there for 5,109 US dollars. But there was no CPT code and no differentiation was made by insurance plan. The hospital side says this is the “basic fee” and what you pay under the insurance may be different. they also to say:
Because your insurance benefits determine your out-of-pocket expenses and the payment for your services is based on contractually agreed rates, the hospital standard fee CDM file is not a useful tool for determining the out-of-pocket expenses you have for your healthcare.
Instead, they recommend using the estimator tool or calling a phone number to get an estimate. Incidentally, this estimate can be higher or lower than what you are actually billed for.
The New York Times recommends complain here if your hospital does not comply with the law but it is hard to find out if it does. If I am a patient or a nurse trying to bill for care, should I also be an attorney and medical billing expert?
Or should I be a literal machine? The UPMC page, after the company claimed that its Chargemaster was “not a useful tool,” offers a machine-readable file that allegedly contains negotiated prices as well as the cash cost of each operation. Using a JSON reader tool, I can see inside well enough to press Ctrl-F and poke around, but I can’t fully understand everything in there. I think I see a cash payment of $ 3,856 for a complete knee replacement and negotiated prices of only $ 395.24, but I’m really not sure I read that correctly.
There’s a bit of hope for the future: With all of these obscure but machine-readable price lists, third-party vendors are likely to show up to read them for you. Turquoise Health is one that the NYT highlights. The local newspaper is near me a tool for area hospitals It’s a bit of a hassle and only shows 70 common procedures, but the results are revealing: In a hospital, insurance companies pay between $ 99 and $ 362 for a mammogram with a list price of $ 713. Medicare pays $ 66 for the same procedure; People paying cash will be charged $ 570.
These price differences are why price transparency is so important, but it’s annoying to navigate through the data just trying to be responsible with your money and health. We hope that when you search for your local hospitals price lists, you find something more informative than me.