Hospital Charges
Beginning January 1, 2019, the U.S. Department of Health & Human Services and Centers for Medicare & Medicaid Services (CMS) are requiring hospitals and health systems to post their current, standard charges.
In accordance with federal requirements, Capital Health provides information on its standard list of hospital charges. Charges are not the same as prices; charges are like a sticker price that is negotiated down for virtually all health care customers. They are contained in a large report called a chargemaster. For example, charge code 5471250 with the description “Diagnostic Imaging – CT Scan of Chest” lists the charge as $19,100. Capital Health is then paid approximately $115. Our goal is for our consumers to have a full understanding of their medical expenses.
Hospital charges are the amount a hospital bills an insurer for a service. For most patients, hospitals are reimbursed at a level well below charges. Patients covered by commercial insurance products have negotiated rates with hospitals. Patients covered by Medicare or Medicaid programs have hospital reimbursement rates determined by federal and state governments.
Hospital charges may include bundled procedures, personnel, services, facilities and supplies. An example would be room rates that include the space, equipment, nursing personnel and supplies.
As a patient, you have the opportunity to shop for medical services. If you are considering care at Capital Health, you should first contact your insurance carrier to understand which costs will be covered and which costs will be your responsibility.
Price Transparency
The information contained herein is in accordance with CMS price transparency requirements which allows healthcare consumers to view standard charges, negotiated rates on “shoppable” services for patients, and access to price estimation as of January 1, 2021.
MS-DRG Price Transparency Information Description and Methods for Inpatient Services
Capital Health’s data set for the inpatient analysis included the prior calendar year’s inpatient discharges in which the in-network health plan issued a payment in accordance with a pre-negotiated rate for the claim.
The Derived Maximum Rate is the estimated maximum reimbursement for a particular DRG across all in-network health plans. The Derived Minimum Rate is the estimated minimum reimbursement for a particular DRG, across all in-network health plans.
Gross Charge represents the total charges billed for all applicable inpatient discharges for a specific MS-DRG divided by the total number of inpatient discharges for that same DRG. For specific DRGs where there were not enough cases to establish a Derived Maximum Rate or Derived Minimum Rate, the DRG and Billed Charges are still displayed (as the Billed Charges figure is calculated across the combination of all health plans). However, in instances where a specific DRG had no utilization during the time period analyzed, the DRG is not displayed. Payer Allowed Amount represents the pre-negotiated rate that Capital Health has with the given health plan. In certain situations, billed codes may be packaged or bundled into the payment of another billed service. In these situations, depending on the nature of the payer’s contract, the gross charges of the additional service items included in the service are listed below the primary code but do not display a Payer Allowed Amount, Derived Minimum and Derived Maximum as the payment is bundled into the primary service. Cash Discount represents what an uninsured patient would pay for the billing code displayed.
Outpatient Shoppable Services
In contrast, a patient is generally considered an outpatient if the service, test, or treatment does not require an inpatient admission order.
Outpatient Price Transparency Information Description and Methods
Capital Health’s data set for the outpatient analysis included the prior calendar year’s outpatient services in which the in-network health plan issued a payment in accordance with a pre-negotiated rate for the claim.
Data excluded from the outpatient analysis includes, but may not be limited to, situations where there were no claims with a specific service for the given health plan, or the coding for the service changed and the code is no longer part of the current charge master.
Gross Charge represents the charge amount for a particular service as listed on the hospital’s chargemaster, or the total charges for a particular outpatient service performed divided by the total number of outpatient services performed for the same service. The Derived Maximum Rate is the estimated maximum reimbursement for a particular service, across all in-network health plans. The Derived Minimum Rate is the estimated minimum reimbursement for a particular service, across all in-network health plans. Payer Allowed Amount represents the pre-negotiated rate that Capital Health has with the given health plan. In certain situations, billed codes may be packaged, or bundled into the payment of another billed service. In these situations, depending on the nature of the payer’s contract, the gross charges of the additional service items included in the service are listed below the primary code but do not display a Payer Allowed Amount, Derived Minimum or Derived Maximum as the payment is bundled into the primary service. Cash Discount represents what an uninsured patient would pay for the billing code displayed.
Select a link below to view Capital Health’s chargemaster, shoppable items, and machine readable file.
Click Here for Capital Health Medical Center – Hopewell, Capital Health at Deborah – Emergency Services, and Capital Health – Hamilton.
Click Here for Capital Health Regional Medical Center, Capital Health – East Trenton, and Capital Health Family Health Center.
For an estimate of your out of pocket expenses for a specific service or for further information related to our charges, please request a price estimate using our online price inquiry form or by calling our Patient Accounts Department at 609-394-6167.
Email: [email protected]