The healthcare industry has previously been reluctant to share prices (charges). This reluctance was a result of huge variation in insurance plans as well as lack of understanding of what charges truly mean. The Affordable Care Act (ACA) and Health Care PRICE Transparency Act mandate the following:
- Provide patients with clear, accessible information about their “standard charges” for the items and services they provide making it easier to shop and compare across hospitals, as well as reducing surprise bills amounts.
- Make hospital standard charges and negotiated insurance rates, along with the amount the hospital is willing to accept in cash from a patient public
- Make public negotiated rates and charges, cash prices, etc. in a manner that is consumer-friendly and up-to-date.
While BCHC agrees with the goal of price transparency, we are concerned about the misinformation that posting our charges and negotiated rates services will create. The issue is that a patient’s out of pocket expense are hardly ever determined by charges alone and only partially determined by negotiated rates. Patient out of pocket expenses vary greatly by the patient’s type of insurance plan and any amount already paid towards a deductible. However, to comply with the law, our hospital will post our complete charge-master to our website which will be updated annually. We also will provide our patients with an estimator tool providing out-of-pockets costs estimates based upon the Current Procedural Terminology (CPT) codes provided along with the individual’s insurance including coinsurance and deductible remaining. The goal of price transparency is to allow the consumer to make a choice not only based on clinical criteria but also financial criteria. While complying with these new mandates may seem like a good first step, the consumer must also learn some of the complexities of healthcare coding (CPT codes), hospital charges, and contractually negotiated rates. The tools we are providing will provide an estimate of the patient’s responsibility for the codes that your physician would need to provide. As you review our charges, here are a couple of things to keep in mind:
- The physician will provide the CPT codes they intend to bill based upon the services they plan to perform dependent on their best clinical judgement. CPT codes could change dependent upon what the physician performed versus what they initially thought. For example, if a surgeon is planning on performing a knee arthroscopy (CPT # 29866) due to what they believe is a torn meniscus, they could change this code to #29881 which is an excision of the meniscus which bills out differently. Surgical estimates will be some of the most difficult items to estimate since each surgeon uses different instruments/resources to complete the procedure.
- Patient deductibles could change dependent upon when a claim is paid by your insurance company. Some claims take 30, 60, or 90 days to go through which might cause a misleading amount of patient responsibility remaining. Overall, if you have met your deductible for the year, you will see very little patient responsibility differences from location to location.
- BCHC can perform many surgical procedures, however estimating surgical procedures can produce variation from hospital to hospital due to many reasons. If large variation exists, it may be worthwhile contacting the hospitals you would like to seek services from.
If you have questions about the information we are providing or would like to speak to a representative, please call our patient financial services department (319-332-0999) and speak with one of our trained health care professionals. Our patient financial services department will review your insurance information, estimate the charges for services and then provide an estimate of what your responsibility will be. At that time, they can look at payment options along with reviewing other services our hospital offers. Our goals is to not only provide the highest level of care for you, but to put your mind at ease with understanding the financial impact this may have on you.
Transparency in Coverage Rule (TCR)
The Transparency in Coverage Rule (TCR) requires self-funded groups and insurers to make two machine-readable files publicly available beginning July 1, 2022, including:
- In-network allowed amount
- Out-of-network allowed amount, if applicable, based on threshold requirements
This link leads to the machine-readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated service rates and out-of-network allowed amounts between health plans and healthcare providers. The machine-readable files are formatted to allow researchers, regulators, and application developers to access and analyze data more easily.