The background: Booked a procedure in a hospital, only to to find out that the total contractual amount (the hospital 'insured' price) is 250% higher than average amount @zip. The quoted price is 22% even higher than the out of network average.[1]
Therefore, I tried getting competing quotes from nearby facilities. The only billing team that responded actually stated they "don't quote patient-portion costs". [3]
They suggested we check their "standard charges" list, which is a JSON file that cannot be opened by firefox. [2] (Can't seem to open with JSON viewer either)
This wouldn't seem to be a reasonable way to deal with patients seeking valid financial info. Do you have experience on successfully getting price info ? And, is there a regulatory agency to complain to due to lack of disclosure ?
[1] https://www.fairhealthconsumer.org/
[2] https://www.nyp.org/patients-visitors/paying-for-care/hospital-price-transparency/standard-charges
[3] Good morning,
The hospital does not process estimates for patients with insurance coverage. However, our web portal contains charges under the Hospital Price Transparency link. I have included the link in the subject line for easy access. As far as out-pocket responsibility, your insurance company is the best source for that information; they will advise if you have any copay for the encounter.
Respectfully,
XXXXXXXXXX
Financial Clearance Center Supervisor
Email: xxxx@nyp.org
______________________________________________
From: XXXXXXXXXXXXXXXXXXXXXXX
Sent: XXXXXXXXXXXXXXXx
To: XXXXXXXXXXXXXXX @nyp.org>
Subject: [EXTERNAL] Patient responsibility inquiry
Hello!
I was told by the very helpful Ms. XXXX, that you would be able to provide patient responsibility amount , related to facility CPT codes for a XXXXX procedure.
For this purpose, I am attaching front and back of my insurance card (XXXXX). The member DOB is xxxxxx. The specific 2 codes in question are :
CPT XXXXX
CPT XXXXX
Can you please provide the total patient cost for the facility charges for the CPTs above, so I know how much we are expected to pay ourselves (after insurance) for this in-network procedure?
Also, can you let me know if there is some kind of additional surcharge / tax ?
Thank you.
Hospitals are required to have a list of standard prices for all their procedures (usually called a “chargemaster”). Hospitals can set these prices basically at their own discretion, but are legally barred from charging more than their chosen amount. Payors (read: insurance companies) often negotiate much better rates than the numbers on the chargemaster, but the hospital can never negotiate to have a payor exceed chargemaster rates. Unsurprisingly, this incentives hospitals to price their chargemasters stupidly high.
Each payor the hospital accepts will have their own negotiated rates, which incentives hospitals to be very secretive about their pricing (all they are required to publish is chargemasters, and that’s a recent development). If you want to keep going down the rabbit hole, you’ll likely have to start bugging your insurance to get more details about the negotiated rates.
However, you’re in a highly-populated area and seem to be looking to get an outpatient procedure done. Depending on the type of procedure, there’s a whole blossoming network of providers who avoid these issues by offering cashpay rates (whole nother rabbit hole I won’t get into for brevity) that can be much cheaper than your deductible, or in the case of surgical stuff, coinsurance. I’d highly recommend looking for one of them if it makes sense in your situation. Happy to offer guidance based on the general category of procedure you’re looking for.
Your experience is not abnormal, and the US medical industry is completely fucked. Hospitals spend billions annually on lobbying (more than big oil), and they’ve accomplished near-total regulatory capture.