As of January 1st, 2021, The Centers for Medicare and Medicaid Services (CMS) requires hospitals to share pricing information for cash (self) pay and for common insurers for 300 “shoppable” services. Those services tend to be defined as non-emergency procedures that patients could shop around for in advance of needing the procedure.
According to CMS, “Hospitals must post standard charges for at least 300 shoppable services that can be planned in advance, along with a description and any other services the hospital customarily provides with it. This includes things such as x-rays, outpatient visits, imaging and laboratory tests or bundled services such as a colonoscopy. You’ll be able to find the hospital’s standard charge for the shoppable service and see other associated costs.”
In very plain language, this means that hospitals are now required to post the self pay and insurance contracted rate of many procedures on their website. Meaning that shopping around for services will be easier than it was before, because that information is now available to the public.
While making this information available has a several complex implications for insurance companies, health systems, employers, and labor unions, it does provide valuable information that savvy consumers can use in their decision about where to have their planned surgeries.
How much does my procedure or surgery cost?
Understanding the cost of a procedure or surgery requires three steps, which we’ve broken down below.
Understand the services that will be provided during the procedure or surgery.
Understand how the procedure or surgery applies to your insurance benefits.
Determine the cost of your procedure or surgery at nearby facilities.
1. How to understand the services that will be provided during the procedure or surgery
For the first step, you need to determine exactly what surgery or procedure you need, and who will be involved in your care.
To determine what surgery or procedure you will need, simply ask your ordering doctor (the doctor who recommended the procedure or surgery) for the CPT code. This is a unique, five digit healthcare code for various types of healthcare services. Learn more about CPT codes here.
Then ask your provider who is typically involved in that procedure. Most care falls into these four categories from a billing perspective:
Facility
Doctor
Lab
Anesthesiology
For example, if you need a general surgery, there will usually be a separate charge (and a separate bill) from the facility where the surgery is performed, the doctor who performs the surgery, and the anesthesiologist.
If you need to have a CT scan, your charges will likely be from the imaging facility and the third party doctor who will read/interpret your scan (who you likely will never meet).
If you need to have a mole removed, your charges will likely be from the facility or doctor (typically not billed separately if done as part of an office visit), and from the third party lab who analyzes the mole.
The prices the hospitals post are the price for the facility. They are typically the highest charge that you will have from a standard surgery.
Helpful questions: What is the CPT procedure code for my surgery? Who should I expect to receive bills from? How many bills should I expect to receive from everyone involved in my care?
2. How does the procedure or surgery apply to my insurance benefits
Healthcare services vary in how they apply to your benefits. For example, some plans have a copay for doctor visits, while for others the cost of the doctor’s visit is applied to the deductible. Most health insurance plans in 2021 apply the cost of surgery to the deductible, but you’ll want to double check with your insurance provider.
Helpful questions: Is the procedure covered under a copay, or does it apply to your deductible? Is the total cost of your surgery more or less than your out-of-pocket maximum?
3. what is the cost of a procedure or surgery at nearby hospitals
In the last step, you’ll need to combine the information from step 1 and 2. Once you know who you can expect to receive bills from and what the procedure code is, you’ll need to find out the insurance contracted rate of that service from that provider with your insurance. This is where the new CMS legislation makes your life much easier. Rather than calling all five hospitals in your area and crossing your fingers that at least one will tell you the contracted rate, CMS requires those hospitals to list their facility fees online. As long as your hospital is complying with CMS regulations and the procedure is one of the 300 “shoppable services,” you should be able to find the contracted rate with your insurance company on the hospital websites. Check out the list at the bottom of this page for direct links to some hospital’s lists.
how does insurance apply to the listed cost of the procedure or surgery
For an in-depth example of how insurance applies to the listed cost of your procedure, check out this link.
What bills am I likely to receive after a procedure or surgery?
Most people receive up to four bills after a planned surgery. Those include bills for:
Facility Fee - The facility fee is the amount the facility (aka hospital) charges for the services you’ve received. Typically that covers the cost of using the space, technology and supplies within the facility/hospital.
Professional Fee - The processional fee is the amount you pay to the doctor or physician group. It typically covers the time and skills of the primary provider. This may be the primary surgeon who performed your surgery, or it may be the radiologist you never meet who reads your MRI.
Anesthesiologist Fee - The anesthesiologist fee is the amount charged for anesthesia and anesthesia services. Most anesthesia is provided by third party anesthesia groups who contract with local hospitals.
Lab Fee - The lab fee is a fee you may pay if a sample is sent to a lab for analysis. Many labs are third party providers who you will never meet.
How do I find the cost of standard procedures at my hospital?
We spent several hours digging around the internet for a list of shoppable services at the major health systems in the US. As of January 2021, many have made their prices lists easy to locate with a basic Google search (ex. “Kaiser Permanente Shoppable Services). However, roughly 30% of the health systems we searched did not have an easy-to-locate list of prices. To find prices for your specific hospital, we recommend searching the following:
[Health System Name, Hospital Name, Shoppable Services]
[Health System Name, Hospital Name, Pricing Transparency]
What if I cannot find a list of prices for common shoppable services at my hospital?
Because this is a legal requirement from CMS, nearly all hospitals are required to post this. If you cannot find the list from a basic google search or the links below, call the hospital and speak to a patient financial services advisor. If they are unable to provide you with the information, CMS does have an avenue for complaint submission.
Links to Shoppable Service Price Transparency Lists
What other information about surgery pricing is available?
Some states have additional resources to assist patients in finding high-quality, low cost care. For example, Texas PricePoint is a resource “sponsored by the Texas Hospital Association, an Austin-based nonprofit statewide trade association representing hospitals and health systems. This site was created to provide basic demographic, quality and charge information on Texas hospitals and to promote consumer/hospital interaction.”
Texas PricePoint provides:
Charge data on the most common inpatient services
Links to quality data
General and contact information for Texas hospitals