Price Transparency

The answer is simple; it depends. Many factors impact how much the patient is responsible to pay even though they have insurance.  

• A few helpful terms which are commonly used when processing the patient’s financial responsibility are deductible, copay, coinsurance, or non-covered service to name a few.

• In simple terms network status means there may be a contract between the hospital and the insurance plan. When a contract exists, the patient is in-network. In absence of a contract, the patient’s insurance is deemed out-of-network.

• Physician services are separately billable to your plan and these too maybe in-network or out-of-network.

• Patients are encouraged to call their insurance plan as it is very possible that either the hospital and/or physician or both maybe in or out-of-network which will increase the patient’s responsibility. These may not always match.

Need help understanding insurance terms? 

Insurance plans can be as unique as care plans. Therefore, patients are highly encouraged to call their insurance plan to confirm benefits, plan design, patient liability and their frequently used terms. Here are a few helpful terms and their respective meaning. 

Coinsurance

This is a percentage for the costs of a covered healthcare service. The patient pays coinsurance plus any deductibles. As an example of 30% Coinsurance: In the event that the health plan's allowed amount for an office visit is $100 and you have met your deductible, your coinsurance payment of 30% would be $30.

Copayment

A copayment is a fixed amount you pay for a covered healthcare service, most often at time of service or before. The amount can vary by the type of covered healthcare service. As an example, a visit to your provider may be $10.00 per visit; in contrast, a service provided by a specialist may be $20.00 per visit. 

Deductible

A deductible is a fixed amount you are expected to pay for healthcare services before your health plan begins to pay for covered services. As an example, if your deductible identified by your health plan is $1,000; your plan will not pay anything until the first $1,000 is paid (or applied; Patient Responsibility).

The deductible may not apply to all services (e.g. preventive services) and may be assigned as an Individual or Family amount. We encourage you to call your insurance plan to discuss your deductible amounts as charges may occur based on services provided (i.e. Individual, Family, met and unmet deductible amounts.)

Explanation of Benefits (EOB)

An Explanation of Benefits (EOB) is a statement sent by your health plan after you receive healthcare services from a provider. For each service, it shows the amount charged by the provider, the plan's allowable charge, the plan's payment, and the amount you owe. EOB's are for informational purposes and are not a bill. 

Health Insurance

Health insurance is a contract that requires your health insurer to pay some or all of your healthcare costs in exchange for a premium. 

Network

In this context, networks are hospitals and other healthcare facilities, providers, and suppliers your health plan has contracted with to provide healthcare services. Services can be either in-network or out of network, possibly during the same date of service. Network status may affect the amount a patient will owe. 

Noncovered Services 

Noncovered services are medical services that are not included in your plan. If you receive noncovered services, your health plan will not reimburse for those services and your provider will bill you, and you will be responsible for the full cost. We encourage you to consult with your health plan, but generally payments you make for these services do not count towards your deductible. 

Out-of-pocket Healthcare Cost

These costs refer to your expenses for medical care that aren't reimbursed by insurance. Out-of-pocket costs include deductibles, coinsurance, and copayments for covered services plus all costs for services that are not covered. 

• Hospital Charges more commonly referred to as Uniformed charges are the amounts set before any discounts. Hospitals are required by the federal regulations to utilize uniform charges as the starting point for all bills. The charges are based on what type of care was provided and can differ from patient to patient for the same service depending on any complication or differences in treatment plans due to patient’s health.
  
  
• Hospital Cost: Is the total expense incurred by the hospital to provide healthcare. Hospitals have higher costs to provide care because the hospital is open 24 hours a day, 7 days a week with availability to cover emergencies.
  
  
• Price is the amount the hospital is expecting as payment. Hospitals are paid by health plans and/or patients, but the total amount paid is significantly less than the starting charges and takes into consideration any contractual discounts.
  
  • Example: Medicare and Medicaid pay hospitals according to a set fee schedule depending on the service provided. Commercial insurers negotiate discounts with hospitals on behalf of their enrollees.
  • In each of these cases hospitals are paid much less than starting charges.

•   When patients are comparing prices between facilities many factors should be considered. Here are a few to keep in mind: 
  • What type of facility is providing the price? Not all facilities are the same; some are Free-standing, others are identified as an Ambulatory Center and still more are licensed as a hospital; each with their own price structure.
  • What is being performed? Charge information is not necessarily useful for consumers because the descriptions can be limited.
  • How many individual charges make up the price for a particular service or procedure? A procedure is comprised of numerous components from several different departments. Here are a few examples: Room & Board, Laboratory, Pharmaceuticals, Therapy, and other diagnostics services.
• Patients are encouraged to work with their provider to obtain the technical name of the procedure or test that has been recommended. Specific CPT and ICD 10 codes will be helpful in obtaining price information.