Price Transparency

What Do These Charges Mean?

Medicare has defined several different types of standard charges that should be available for patients to see. They are:

• Hospital standard charges
• Self-Pay standard price
• Payer-specific standard charge
• Minimum standard charge
• Maximum standard charge

Hospital Standard Charges

The hospital standard charge is the full list price from the hospital chargemaster or CDM (charge description master). Each hospital sets a gross charge for every individual service rendered to patients within their chargemaster. These standard charges do not include any discounts that may be offered, and they serve as the starting point from which payment is negotiated with individual insurance payers for specific insurance plans. As a patient receives services throughout the hospital visit, a charge for each service provided is generated on the patient’s account resulting in a claim that is submitted to the patient’s insurer.

Patients will almost never pay the listed standard charge for health care services. However, under federal law, all insurers, including Medicare and Medicaid, must be billed the amount listed on the chargemaster for those services

Standard charges can vary, sometimes greatly, from hospital to hospital for the same procedure or service based on how each hospital manages its charges and costs. Charges can vary based on geography, physician supply and medication preferences, the kinds of services the facility typically provides, and the expertise required to deliver these services. Depending on which (if any) group purchasing organization the hospital is a part of, drug and supply costs can also vary greatly

Self-Pay Standard Charge

The self-pay standard charge is the discounted price offered to patients willing to pay in cash at the time of service without involving insurers. This is often referred to as the self-pay price.

Payer-Specific Standard Charge

The payer-specific standard charge is the charge that a hospital has negotiated with a third-party payer for an item or service. This negotiated charge amount will likely vary from payer to payer and even between insurance plans for the same insurance payer.

Minimum Standard Charge

The minimum standard charge is the lowest charge that a hospital has negotiated across all insurers for an item or service.

Maximum Standard Charge

The maximum standard charge is the highest charge that a hospital has negotiated with all insurers for an item or service.

Understanding the Price Transparency Machine-Readable File

Pricing for all items and services (chargemaster)

This is a comprehensive list of charges for each inpatient and outpatient service or item provided by a hospital – each test, exam, surgical procedure, room charge, etc. Given the many services provided by hospitals 24 hours a day, seven days a week, a chargemaster contains thousands of services and related charges

The chargemaster amounts are billed to an insurance company, Medicare, or Medicaid, and those insurers then apply their contracted or fee schedule rates to the services that are billed.

Shoppable Services

The high degree of variation in charging practices and differences in reimbursement methodologies between insurance payers make it difficult for patients to get the intended full-benefit of “pricing transparency.” Medicare wanted to give patients another way to compare prices, so the requirement asked hospitals to make prices available for shoppable services or items in a patient-friendly format.

Medicare defines “shoppable services” as services that typically can be scheduled by a patient in advance on a non-urgent basis. Medicare has identified 70 shoppable services that all hospitals should include and has asked hospitals to choose at least 230 additional shoppable services that they perform most frequently.

Financial Assistance

Financial counselors are available to answer your questions about financial assistance programs that may be available to you.

You have the right to receive a “Good Faith Estimate”

Under the law, health care providers need to issue patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
• Your health care provider will issue you a Good Faith Estimate in writing at least 1 business day after you scheduled your visit, if scheduled 3 business days prior, or 3 business days after you scheduled your visit, if scheduled at least 10 business days prior.
• You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• The information provided in the good faith estimate is an estimate only and the actual charges for the items/services may differ from the estimate. Charges may vary from facility and provider estimates due to unforeseen circumstances including but not limited to complications and/or change(s) in diagnoses and/or treatment plans ordered by your provider.
• There may be additional items or services the convening provider or facility recommends as part of the course of care that must be scheduled or requested separately and are not reflected in the good faith estimate.
• The good faith estimate is not a contract and does not require uninsured or self-pay patients to obtain the items or services from any of the providers or facilities identified in the good faith estimate.
• Save a copy of your Good Faith Estimate.
• For questions or more information about your Good Faith Estimate, please call 414-805-6206.
• You have the right to initiate the patient-provider dispute resolution process, if the actual billed charges are $400 or more in excess of the expected charges included in the good faith estimate. The patient-provider dispute resolution process will not adversely affect the quality of health care services furnished to an uninsured or self-pay patient. You can find information about how to initiate the patient-provider dispute resolution process at www.cms.gov/nosurprises/consumer-protections/Payment-disagreements.