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Ask HN: How does HN obtain hospital procedure “quotes”?

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.

nitwit005 5y ago
I assume this is the US? I haven't personally tried, but journalists have tried and failed to get quotes out of hospitals. I have sat in the back office of a radiology clinic. They gave out exact prices to people, as they were doing the same set of procedures all day, and had a lot of experience with the insurance.
epc 5y ago
The file can be processed with jq [https://stedolan.github.io/jq/ https://stedolan.github.io/jq/], I had to invoke it as "jq . 133957095_NewYorkPresbyterianHospital_standardcharges_12312020_Updated07232021.json". But it should work to look up a CPT and get the cost.
- IG_Semmelweiss 5y ago
  thank you!
boas 5y ago
Another thing to keep in mind is that “one” procedure often involves multiple CPT codes. Sometimes the CPT codes change during the procedure, based on what the surgeon finds. The hospital should be able to give you an estimate of the cost. Ask your surgeon to help if you are having problems getting information.
- IG_Semmelweiss 5y ago
  Correct. I provided said CPT codes. One thing to note - it was vaguely suggested having the ICD10 codes (diagnostic codes) would help. Though not sure if that was accurate or not
deleted 5y ago
[deleted]
wswope 5y ago
This is my wheelhouse, so let me back up and offer you some context: 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.
- IG_Semmelweiss 5y ago
  Update: I went down the rabbit hole: Tried calling insurance, and the concierge 3rd party servicer was helpful. (Big factor: plan is "Platinum+" plan). After 1 hour on the phone, the concierge provided the best priced "negotiated" facility rates nearby. So now we know what is available. One price was 75% below the price quoted by the original facility after scheduling. However, now we need search the doctors with surgery privileges in the price-competitive facilities. I can't believe I am going to say this but I think at this point I'm ready to proceed with Cashpay. Can I email you for guidance ? (i don't want to disclose procedure here).
  - wswope 5y ago
MiddleEndian 5y ago
>Do you have experience on successfully getting price info ? Nope. Even afterwards. After I found myself in the ER, I went back a month later and told them I wished to pay the bill in its entirety right now, and they still wouldn't tell me how much I owed them.
codegeek 5y ago
"The hospital does not process estimates for patients with insurance coverage" Sums up why our healthcare system is so fucked up in the US. Good luck trying to find out what it actually costs. I thought the Trump administration passed a law that hospitals must share their prices transparently. I am guessing no one cared to enforce and they are bypassing the law through loopholes.
- IG_Semmelweiss 5y ago
  That rule was neutered when Trump admin lost the White House. https://www.natlawreview.com/article/cms-backs-price-transparency-providers-and-plans https://www.natlawreview.com/article/cms-backs-price-transpa...

nitwit005 5y ago

I assume this is the US? I haven't personally tried, but journalists have tried and failed to get quotes out of hospitals. I have sat in the back office of a radiology clinic. They gave out exact prices to people, as they were doing the same set of procedures all day, and had a lot of experience with the insurance.

epc 5y ago

The file can be processed with jq [https://stedolan.github.io/jq/ https://stedolan.github.io/jq/], I had to invoke it as "jq . 133957095_NewYorkPresbyterianHospital_standardcharges_12312020_Updated07232021.json". But it should work to look up a CPT and get the cost.

IG_Semmelweiss 5y ago
thank you!

boas 5y ago

Another thing to keep in mind is that “one” procedure often involves multiple CPT codes. Sometimes the CPT codes change during the procedure, based on what the surgeon finds. The hospital should be able to give you an estimate of the cost. Ask your surgeon to help if you are having problems getting information.

IG_Semmelweiss 5y ago
Correct. I provided said CPT codes. One thing to note - it was vaguely suggested having the ICD10 codes (diagnostic codes) would help. Though not sure if that was accurate or not

deleted 5y ago

[deleted]

wswope 5y ago

This is my wheelhouse, so let me back up and offer you some context: 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.

IG_Semmelweiss 5y ago
Update: I went down the rabbit hole: Tried calling insurance, and the concierge 3rd party servicer was helpful. (Big factor: plan is "Platinum+" plan). After 1 hour on the phone, the concierge provided the best priced "negotiated" facility rates nearby. So now we know what is available. One price was 75% below the price quoted by the original facility after scheduling. However, now we need search the doctors with surgery privileges in the price-competitive facilities. I can't believe I am going to say this but I think at this point I'm ready to proceed with Cashpay. Can I email you for guidance ? (i don't want to disclose procedure here).
- wswope 5y ago

MiddleEndian 5y ago

>Do you have experience on successfully getting price info ? Nope. Even afterwards. After I found myself in the ER, I went back a month later and told them I wished to pay the bill in its entirety right now, and they still wouldn't tell me how much I owed them.

codegeek 5y ago

"The hospital does not process estimates for patients with insurance coverage" Sums up why our healthcare system is so fucked up in the US. Good luck trying to find out what it actually costs. I thought the Trump administration passed a law that hospitals must share their prices transparently. I am guessing no one cared to enforce and they are bypassing the law through loopholes.

IG_Semmelweiss 5y ago
That rule was neutered when Trump admin lost the White House. https://www.natlawreview.com/article/cms-backs-price-transparency-providers-and-plans https://www.natlawreview.com/article/cms-backs-price-transpa...