January 1st, 2021, all hospitals are required to display at least 300 “shoppable medical Services “that a health care consumer can access prior to having a procedure. The goal is to give greater transparency to people who wish to be better consumers of health care.
The medical providers are supposed to display these services in a “consumer friendly’ format. They have to list:
- Discounted Case Price– The cost of the procedure for someone that pays cash.
- Payer-Specific Negotiated Charge– This is the charge the hospital has pre-negotiated with third-party payers like an insurance network.
De-Identified Maximum Negotiated Charge: The highest charge the hospital has negotiated with a third party.
Let’s look into the transparency rules and how they actually work in central Indiana. We thought we would look at Community, St Vincent’s (Ascension) & IU Health.
First, finding the transparency page is not easy as it does not show up on the website’s first page. We would expect the medical providers to have the link at the bottom of the page. On a couple of the medical providers, we had to search for the transparency page through a search engine as we could not find it. Once you find the transparency link be prepared to enter your health insurance information. This allows for the “Payer Specific Negotiated Charge- to be shown.
Next, you will need to brush up on your medical billing coding, which is necessary to get to the “user-friendly” transparency information. We thought we would use CPT code 73718- MRI LOWER EXTREM OTH/THN JT W/O CONTR MATRL
St Vincent’s Carmel– List the procedure at $1,185 after insurance. The cash discount price is $570.
IU Health is taking our insurance information and running an electron feed where you can see where you are year to date on your deductible and how much of the procedure would apply to your out-of-pocket max. IU is not allowing a quick CPT code search but a more in-depth definition of the procedure. IU estimates the cost $3,732.88 with a network discount of $2,227.13 = $1,505.75 & professional charge of $159.07 services. We run the costs with no insurance, “Discounted Cash Price” $893.72 and professional service $219. At IU Health, the procedure would cost the insured less to go with the cash discounted price.
At the Community Health Network, we can use the CPT code with the insurance policy, and it takes us directly to the cost of the procedure. The total list fees $2,536- Then Insurance covers $1,836, which is the insurance network discount, and you pay $700. If we remove the insurance and look at the cost, $2,536 is still the charge with a $1,014 discount leaving the patient with $1,522.
We looked at a few of the surrounding hospital’s transparency:
Quick Recap of the “consumer-friendly” transparency report:
- IU Health- $1,505 after insurance
- IU Health- $893.72 with no insurance/Cash discount.
- St. Vincent’s- $1,185 after the network discount.
- St. Vincent’s- $570 with the cash discount.
- Community Health- $700 after insurance
- Community Health- $1,522 Cash discount.
- Franciscan- $1,168 after Insurance.
To shop out one CPT code with multiple hospitals took a couple of hours. It isn’t easy to find the transparency tabs on the hospital’s web page. After finding the search tab through additional search engines, you have to click through multiple pages to get results. Each site has different requirements to search. One needs basic medical knowledge on the procedure they are researching along with the CPT code.
There is now a path to research the cost of medical procedures. The medical provider is not making it easy, but they are doing their best to provide information. Until the process becomes streamlined, which is a will, many consumers will not know how or have the resources to research the cost, but there is the option of calling the hospital.