CMS previously has passed rules about cost transparency. For hospitals in my area you can search the Chargemaster and view cost info for all procedures, but it is not easy to understand. For the most accurate info, you need the code associated with the procedure. Some have searchable database per insurance company, some the data is months old. The data is for the specific institution, not a comparison to other facilities.
Our insurance has always sent an EOB that lists the billed price, allowed amount under the plan contract, amount the insurance pays (90% if in-network), and my share (10% if in-network). Itâs easy to see how much different the billed vs contracted rate are.
Anesthesiologist for my knee replacement:
Charged $1280, $209.99 is contracted rate
Ins paid $188.99, I paid $21.
Out-of-network is 25% copay PLUS the amount over the allowable.
Knee replacement surgeon:
$12500 billed, $5166.05 is allowable rate
Ins paid $3873.76 (75%), I paid 1287.25 (25% non-network copay) PLUS $7338.99 amount not allowed, for a total of 8626.84.
Knee surgeon knocked $4000 off my share of the bill. (and we were HAPPY!) We got a âno surprisesâ bill and it only listed the full charge â no indication of what insurance would pay or what our OOP would look like.
The hospital where I had the knee replacement charged $39k for hospital fees. Itâs in-network; I expect the allowable will be between 19-21k.
When I had my cardiac arrest ten years ago, a hospitalist checked on me every day (not that I remember; I was in a coma, and had been in full arrest when I arrived in the ER, so itâs not like I got to choose my doc or ask if she was in-network). Her practice worked ONLY for the in-network hospital where I was sent, and she was out-of-network and wouldnât budge on the fee. It annoyed me, but it was the only copay out of $100k+ in bills that we had.
Every time I get an EOB in the mail, Iâm reminded how stacked the system is and how people with lousy plans or no coverage get totally and utterly bleeped by this system.
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Pricing transparency does more than letting consumers choose. When prices are opaque, thereâs no incentive to eliminate inefficiencies in the system because the extra cost can be buried and passed on to the consumers. With price transparency, the service providers who overcharge are apparent, and so are the less efficient providers. Competitions among the service providers would drive down the cost.
Pricing transparency would also likely change consumersâ behavior even if they only indirectly pay for the services, because they know they have to ultimately bear the cost.
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I was grateful to have relatively low out of pocket maximum limits for each family member and our entire family every year, especially when we were needing a lot of medical care.
Pricing transparency would definitely be an improvement, so patients can be better informed. I tried to get a price quote as to how much it would cost for 3D imaging follow up of an ambiguous mammogram and couldnât get any straight answers. It was very frustrating. Fortunately it wasnât terribly expensive and we could afford it but it would be a huge issue for folks who were afraid of a huge hole in their budgets .
The no surprises act addresses the dr and hospital charges, which is a little different than the insurance allowable.
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Where do I go to get this information?
The original post links to an NPR article that says: " As of July 1, health insurers and self-insured employers must post on websites just about every price theyâve negotiated with providers for health care services, item by item."
My insurer has no information on their website about this.
You will need to ask your insurer. Note there is no requirement that they have to make the information understandable or easy to search/sort in a way that a consumer might be used to seeing. For now, many are likely to simply make very large and difficult to understand databases available for download.
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Yes ours always does this too. But I think the difference is that now you will be able to know these charges before you go to the doctor instead of afterwards. So you can shop around. Or at least thatâs my understanding.