How to find out the prices for medical services in hospitals in New York and the USA

This year, some Americans can do what was previously impossible: find out the cost of treatment before going to the hospital. A new federal rule requires hospitals to publish the prices they negotiate with private insurers, reports New York Times.

Based on this data, the Times concludes that some insurers pay twice or three times more for basic services than their competitors. Paying in cash instead of using insurance can significantly reduce the cost of treatment.

But most hospitals have not yet published the required data. Even if they are, finding it can take time and energy. Also, you may need to be a programmer to get this information.

“Drink some coffee because it will take some time,” said Thure McCluskey, co-founder of medical startup Redu Health, which compiled some of the data files. “The information is there, but it is inconvenient for the consumer to study.”

What do you need to know

Before you start looking for prices, you need to know what kind of health insurance you have. For example, whether you chose an HMO plan during open enrollment or chose the PPO option.

Insurers often have half a dozen rates in the same hospital. Some depend on which plan you choose and whether you purchased insurance through Obamacare or from a specific employer. Others are related to which network you chose when you signed up for coverage.

Knowing your insurance type will help you understand which prices in the data apply to you.

Then do a web search

For most hospitals, the data is posted on a page labeled Price Transparency. Many researchers say they start looking for price files by searching Google for that phrase and the name of the hospital.

The page should look similar to this page of the MedStar Hospital Center, the largest hospital in Washington, Columbia region.

A hospital site dedicated to price transparency is likely to have several sections and links, and the labeling of price files is not always clear. You need to find something like "complete machine-readable file" or "agreed price list".

It's also worth opening files that are described as containing "standard charges" or "chargemaster". On the website of the Indiana Medical University Hospital, for example, they look like this:

When you open the files, what you see is that it actually contains the hospital's negotiated rates and cash prices.

That's what you are looking for

The government has not created a standard format for hospitals to report their price data. In addition, each hospital takes a slightly different approach.

A typical data set is prices per procedure for each insurance company. For example, on the University of Pennsylvania Hospital website, the five-digit numbers at the very left of the spreadsheet are CPT codes that are used to describe each service they offer. Most files also have brief descriptions for each code, but these can be confusing. The code U0003, for example, translates to “PR COV 19 AMP PRB HIGH THRUPUT,” a slangy way to describe a coronavirus test.

To find out the cost of a particular service you expect to receive at the hospital, you will likely need to call the facility and ask what CPT codes will be issued for your visit.

You may also see other numeric codes, sometimes called procedure codes or income codes, as in the file below from Baptist Medical Center in Little Rock, Arkansas. You probably don't need to pay much attention to them and should focus on the CPT codes.

Prices may be in dollars or as a percentage of the total.

Usually you should see dollar figures representing real prices. But you may encounter files that list the price as "variable". This means that it may be different for two patients with the same insurancewho received the same assistance under different circumstances.

Molly Smith, vice president of public policy for the American Hospital Association, illustrated this difference with two patients: one came to the hospital for a flu vaccine and the other received it before surgery.

The files must also include two other prices: the "fee" or the "gross price", which is a fixed price for a given service. The second hospital is often used as the basis for negotiating discounts. There should also be a "cash" price that the hospital charges for uninsured patients. The availability of this price for insured patients varies from hospital to hospital. Some low-income patients may qualify for even higher discounts based on how little they earn.

Once you find the right data point, it may take more work to understand it. Most hospitals list prices in dollars, but some display data as a percentage of the total cost This means that patients will need to perform mathematical calculations to understand their costs.

What if I don't find anything

Most hospitals have not published the required data, so this can happen in many cases.

For example, on NYU Langone's price transparency website, you can only find standard fees and a patient assessment tool that uses information about your insurance plan to create a personalized estimate of how much you will pay for a particular procedure.

These tools provide limited information. Standard fees can tell you the maximum amount you can pay for a given service, while a patient estimator shows out-of-pocket costs associated with simple services such as mammograms and blood tests. However, when a Times reporter attempted to use the NYU site in late July, he returned error messages for all the services he examined.

An NYU spokesman for Langon declined to comment on why the hospital did not release the full figures.

With compliance still low, the federal government is promising to step up enforcement. The government has sent nearly 170 warning letters to non-compliant hospitals and plans to increase fines for non-compliance from $109 a year to $500 million.

If you believe that the hospital has not posted the required information, you can make a complaint to the federal government, notifying them of the problem.

Many hospitals do not disclose key pricing data

A survey of 1000 hospitals across the country conducted between December and January found that only about 14% were fully compliant with price transparency rules. Gothamist. None of the 12 hospitals in New York and Long Island were among them.

The results were published this month in PatientRightsAdvocate.org report, a non-profit organization that promotes price transparency as a way to empower patients and reduce healthcare costs. The group found that compliance increased from about 5,6% in July 2021, but remains low.

The report shows that many New York City hospitals are following the federal rule to some extent, but are not disclosing certain key information.

Critics have said earlier that the federal government's plan to fine hospitals $300 a day for violating the price transparency rule is not enough to force them to disclose their rates. In November 2021, the U.S. Centers for Medicare and Medicaid Services (CMS) announced that they would be penalizing hospitals with more than 30 beds up to $5500 per day, or about $2 million per year.

But there have been no fines so far, CMS spokeswoman Patrice Martin confirmed. As of last month, CMS has sent out warning letters to 342 hospitals that weren't following the rules and issued 126 requests for corrective action plans as of last month, Martin said. She did not say if any of these messages were for New York hospitals.

Third Party Sites May Help Soon

Some health experts say big data files will become more useful as third-party data companies clean up and organize information so patients can search across multiple hospitals and health services.

One data transparency company, Turquoise Health, has already created a free price lookup tool. Others are expected soon.

Is price transparency possible?

Cynthia Fisher, founder and CEO of PatientRightsAdvocate.org., is optimistic about what price transparency can achieve if hospitals follow the law, calling it "a revolution in healthcare that puts the power in the hands of the consumer."

She envisions a time when anyone can easily use an app or search engine to compare the cost of an MRI scan from each healthcare provider in their area according to a specific insurance plan, just as one might compare airline prices when planning a trip. Currently, estimates of medical expenses provided by hospitals to patients in advance are not mandatory. But Fischer said there's no reason they can't be mandatory.

Experts are skeptical about the possibility of a transparent market

Some health policy experts who study consumer behavior are skeptical that such a market exists.

“Overall, we didn’t find that [past] price transparency efforts had the effect that politicians and others had hoped for,” said Ativ Mehrotra, an associate professor of health policy at Harvard Medical School who conducted the price study. transparency initiatives.

Mehrotra noted that many patients are either unaware of pricing tools when they are available or refuse to use them. He added that consumer behavior is also affected by factors other than spending. For example, a referral from a doctor or which health care providers are in someone's insurance network.

However, that doesn't mean cost information is useless, as it can indicate which hospitals have the highest prices, Mehrotra said. “Hospitals really care about their reputation,” he added.

New York City unions and others, including PatientRightsAdvocate.org, formed the Affordable Hospitals Coalition in October to push for lower prices and more accountable local hospitals. Coalition member 32BJ SEIU recently expelled New York-Presbyterian from its network of health plans due to huge bills and held rallies calling on the health care system for a solution.

The New York-Presbyterian said in a statement: “We care about everyone who walks through our doors, regardless of ability to pay. We are one of the largest Medicaid providers in the state and have an extensive financial assistance policy."

How NYC hospitals get around the law

Many hospitals only partially comply with federal transparency rules. For example, a report by PatientRightsAdvocate.org showed that about 85% of hospitals provided tools for national cost estimation. They did not, however, list the discounted cash price, which can sometimes be cheaper than the amount a patient pays out of pocket for insurance. Many hospitals have posted a file listing some of the rates they have negotiated with insurers for various procedures. Yet most have not included all of their prices or rates for all of the health plans they accept.

According to the report, some New York hospitals were close to meeting the requirements. For example, Mount Sinai Hospital, while not listing discounted cash rates, does include a full list of rates for health insurance plans. Mount Sinai did not respond to a request for comment.

According to the report, some hospitals have not made public the rates they charge insurers:

• Montefiore Medical Center,
• Maimonides Medical Center,
• Stony Brook University Medical Center
• NYU Langon Tisch and Winthrop Hospitals.

According to the report, New York-Presbyterian/Weill Cornell Medical Center did not list rates for some health plans, but included others.

Northwell Health responded to a request for comment on three hospitals that the report says are ineligible for a variety of reasons: North Shore University Hospital, Long Island Jewish Medical Center and Lenox Hill Hospital.

Sophisticated web tool

All hospitals have "implemented a sophisticated web-based pricing tool" and "a file that contains information about the cost of various services," said Barbara Osborne, a spokeswoman for Northwell. She added: "These hospitals continue to evaluate ways to improve their approach."

A similar price transparency rule for health insurers should go into effect in July, potentially giving consumers more information to consider when choosing a health plan. Despite the limited application of the hospital rule, Fischer is also optimistic about the measure.

Information from Health+Hospitals

In NYC Health + Hospitals strive to provide as much information as possible so that New Yorkers can make informed decisions about their care. This includes providing you with a list of hospital charges and out-of-pocket estimates for the most common services that H+H provides.

You can get an estimate of your out-of-pocket expenses for many services before your visit through MyChart or by calling 1-844-692-4692 and selecting option 3 to speak with a financial advisor. H+H staff can help provide a comprehensive assessment based on information about your health insurance and benefits, as well as your financial situation.

Hospitals are also required to provide applicable contractual fees with insurance companies for hospitalization and outpatient care. These agreed expenses do not reflect the amount that you, as a covered patient, will be required to pay NYC Health + Hospitals as personal expenses. These fees may also not reflect the actual amount ultimately paid by insurers. You can access the list here.

Calculator

NYC Health + Hospitals also maintains a Patient Cost Estimate Tool that provides you with an estimated out-of-pocket cost for the most commonly provided services that can be scheduled in advance. These services are also referred to as "purchasable services". This estimated out-of-pocket cost is based on your coverage information or self-pay status at the time you requested an estimate. This estimate is not a guaranteed price or coverage by your insurance plan. But it does include an estimate of the fee that the insurer has agreed for the service, if applicable. Your actual out-of-pocket costs may vary depending on your health insurance and benefits, medical condition, and any additional tests or procedures ordered by your physician at the time of service. You can access the cost estimate tool here.

What you need to know about grades

Ratings, also known as "Good Faith Ratings", are based on information available at the time of your request. They include any unknown or unforeseen costs that may arise during treatment. You may be charged additional fees if there are complications or special circumstances. In this case, the federal law allows you to challenge (appeal) the bill.

You can call us at (844) NYC-4NYC (692-4692) and let us know that your billing is higher than our fair estimate and ask us how we can help.

If the staff does not help you directly, you can also initiate a dispute resolution process with the U.S. Department of Health and Human Services (HHS) if you are billed $400 or more in excess of your estimate. If you choose to use the dispute resolution process, you must initiate the dispute process within 120 calendar days (approximately 4 months) from the date shown on the original invoice.

There is a $25 fee to use the dispute process. If the agency handling your dispute agrees with you, you will have to pay the price of that good faith assessment. If the agency disagrees with you and agrees with NYC Health + Hospitals, you may have to pay a higher invoice amount.

To ask questions or learn more about your right to a Fair Evaluation or the dispute process, please visit www.cms.gov/nosurprises.