It’s notoriously difficult to find out how much you’ll pay for a surgery or procedure before it happens. For one thing, hospitals don’t charge everybody the same rates; they negotiate prices with insurers and often try to keep the exact numbers secret. There’s good news, though: A federal law now requires hospitals to post their price lists. There’s also bad news: The lists are often hard to find and even harder to read.
This topic came up when we talked with investigative journalist Dan Weissman on the Upgrade recently, and he told us that the law hasn’t necessarily made it any easier to shop around—although that may depend on your hospital and the state you live in.
Now, the New York Times has published their own guide to finding your local hospitals’ price lists. It’s a multi-step process, and you may not be successful, because lots of hospitals have not complied with the law or have chosen to do it in a way that’s difficult to navigate. But there is hope. Here’s what they recommend:
- Know your exact healthcare plan. It’s not enough to know that you have United, for example. Get specific. Do you have an HMO or PPO? Did you get it through an employer or buy it from an ACA marketplace?
- Google “price transparency” and the hospital’s name. From there, look for something on the hospital’s website that says “chargemaster” or “standard charge listing” or “comprehensive machine-readable file” or “negotiated price list.”
- Look for CPT codes, 5-digit numbers that stand for specific procedures or services. You may need to call the hospital and ask which CPT codes will be billed for the procedure you’re getting.
- Look for prices. There may be columns for a base rate, different insurers, and the price they charge if you’re paying cash.
Unfortunately, there is not a standard file format that hospitals are required to use, so what you’re able to find might vary. And some haven’t posted theirs at all.
Does this work in practice?
With all the warnings, I didn’t have high hopes, but I took the procedure for a test run.
I tried using the steps above for a hospital that is local to me (in the UPMC network), and the initial Google result took me to a price estimator. I had to click through a screen acknowledging that the prices given were just an estimate and not guaranteed, and even then I couldn’t find some common procedures, like a knee-replacement surgery. This is not the webpage I was looking for.
So I went back and threw “standard charges” into my Google search, and this time, I got to a different page that had prices. I even found “TOTAL KNEE PRIMARY” on there for $5,109. But there was no CPT code, and it didn’t differentiate by insurance plan. The hospital’s page says that this is the “base charge” and that what you end up paying after insurance may be different. They also say:
Because your insurance plan benefits determine your out-of-pocket costs and payment for your services is based upon contracted rates, the hospital CDM file of standard charges is not a useful tool for determining out-of-pocket cost that you will pay for your health care.
Instead, they recommend you use the estimator tool or call a phone number to get an estimate. That estimate, by the way, may be higher or lower than what you actually get charged.
The New York Times recommends filing a complaint here if your hospital doesn’t seem to be complying with the law, but it’s hard to figure out if that’s the case. If I’m a patient or caregiver trying to price out care, am I also supposed to be a lawyer and a medical billing expert?
Or, for that matter, am I supposed to be a literal machine? The UPMC page, after all the business saying that its chargemaster is “not a useful tool,” provides a machine-readable file that they say does include negotiated prices, as well as what each procedure costs cash. Using a JSON reader tool, I can see into it well enough to Ctrl-F and poke around, but not to fully understand everything that’s in there. I think I see a cash pay rate of $3,856 for a total knee replacement, and negotiated prices as low as $395.24, but I’m truly not sure if I’m reading it right.
There is a bit of hope for the future: With all those inscrutable yet machine-readable price lists out there, third-party companies are likely to pop up to read them for you. Turquoise Health is one the NYT points out. In my area, the local newspaper has a tool for area hospitals that is a tad clunky to use and only shows 70 common procedures, but the results are enlightening: At one hospital, insurance companies pay anywhere between $99 and $362 for a mammogram with a list price of $713. Medicare pays $66 for the same procedure; people who pay cash are charged $570.
This disparity in prices is the reason price transparency is so important, but it’s infuriating trying to navigate the data when you’re just trying to be responsible with your money and your health. Here’s hoping that if you go looking for your local hospitals’ price lists, you’ll find something more informative than I did.