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. Click here to view our chargemaster. For example, charge code 5471250 with the description “Diagnostic Imaging – CT Scan of Chest” lists the charge as $15,785. Capital Health is then paid approximately $123. 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.
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.
Healthcare services are divided into two larger categories: Inpatient and Outpatient. A patient is considered an inpatient when an inpatient admission order is written. Inpatients are further divided by MS-DRG (Diagnosis Related Groups).
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. Each claim was regrouped into the applicable, current year CMS MS-DRG (whether or not the health plan’s reimbursement is actually dependent on a billed MS-DRG) and into an applicable payer class (e.g. Commercial, Medicare HMO, etc.). In situations where the health plan reimburses via a methodology other than CMS MS-DRG, an attempt was made to convert the actual payment into an approximation of the reimbursement the health plan would have made if the plan reimbursed Capital Health using an MS-DRG methodology and the inpatient discharge’s length of stay was equal to Capital Health’s average length of stay for that specific MS-DRG.
Data excluded from the inpatient analysis includes, but may not be limited to, situations where there were not enough claims of a specific DRG within that payor class, billed charges for the claim exceeded a predefined outlier threshold, or the health plan’s contracted reimbursement changed significantly from the prior period to the current period, making the reimbursement no longer relevant to the maximum and minimum calculations.
The Derived Maximum Rate is the estimated maximum reimbursement for a particular DRG, within that payor class. The Derived Minimum Rate is the estimated minimum reimbursement for a particular DRG, within that payor class. Capital Health did not have an adequate data set to generate a Derived Maximum Rate or Derived Minimum Rate for any DRG for the Worker’s Compensation and No Fault payer class.
Billed Charges 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 for a given payer class, the DRG and Billed Charges are still displayed (as the Billed Charges figure is calculated across the combination of all payer classes). However, in instances where a specific DRG had no utilization during the time period analyzed, the DRG is not displayed.
Click here for Inpatient DRG rates.
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’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. In situations where the health plan reimburses via a methodology other than CMS APC, an attempt was made to convert the actual payment into an approximation of the reimbursement the health plan would have made if the plan reimbursed Capital using an APC methodology.
Data excluded from the outpatient analysis includes, but may not be limited to, situations where there were not enough claims with a specific service within that payor class, the service was billed with modifiers that may impact the reimbursement, the claim exceeded a predefined outlier threshold, or the coding for the service changed and the code is no longer part of the current charge master.
The Derived Maximum Rate is the estimated maximum reimbursement for a particular service, within that payor class. The Derived Minimum Rate is the estimated minimum reimbursement for a particular service, within that payor class. 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 and the payer’s ability to note which services are bundled together, the bundled service was either excluded from the analysis, or the reimbursement was prorated across all services billed on the claim.
Billed Charges represents the standard, current charges reflected on Capital’s Chargemaster and billed out to all patients.
For specific services where there was not enough information to establish a Derived Maximum Rate or Derived Minimum Rate for a given payer class, the Billed Charges are still available on Capital’s Chargemaster report.
Click here for Medicare Advantage plans.
Click here for Medicaid HMO plans.
Click here for Commercial plans.
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 609-394-6316.
Email: [email protected]