WHAT IS THE CMS FINAL 2019 IPPS RULE REQUIRING HOSPITALS TO POST "STANDARD CHARGES"?
The Centers for Medicare & Medicaid Services on Aug. 2 published its final inpatient prospective payment system, or IPPS, rule (see pages 2135-2142) for federal fiscal year 2019. The IPPS rule contains a transparency provision that will be effective Jan. 1, 2019.
The Affordable Care Act included a requirement for all hospitals to establish, update and make public a list of the hospital's "standard charges" for items and services provided by the hospital, including for Diagnosis Related Groups, DRGs. This information is to be made available each year.
CMS, in the 2015 final rule issued guidelines for how hospitals should comply with this requirement, including the following two options:
1.Make public a list of the hospital's "standard charges" (whether that is the chargemaster itself or in another form of its choice); or
2.Make public the hospital's policies for allowing the public to view those charges in response to an inquiry
In the 2015 rule, CMS indicated hospitals could satisfy the ACA requirement by posting information on the internet, but did not make that method a requirement, concluding that "hospitals are in the best position to determine the exact manner and method by which to make the list public..."
CMS also expected hospitals to update the information at least annually, or more frequently if warranted, to reflect current charges.
2019 FINAL IPPS RULE
In its proposed and final 2019 IPPS rules, CMS acknowledged Chargemaster data are "not helpful to patients for determining what they are likely to pay for a particular service or hospital stay."
However, in an effort to continue moving the needle on price transparency, the final rule requires hospitals to make available a list of their current "standard charges" via the internet in a machine-readable format, and to update it at least annually.
This requirement can be met in the form of the Chargemaster itself or another form of the hospital's choice, as long as it is in machine-readable format.
WHAT IS A CHARGEMASTER?
A Chargemaster is a comprehensive list of charges for each inpatient and outpatient service or item provided by a hospital - each test, exam, surgical procedure, room charge, etc. Given the many services provided by hospitals 24 hours a day, seven days a week, a Chargemaster contains thousands of services and related charges.
Chargemaster amounts are almost never billed to a patient or received as payment by a hospital. The Chargemaster amounts are billed to an insurance company, Medicare, or Medicaid, and those insurers then apply their contracted rates to the services that are billed. In situations where a patient does not have insurance, our hospital has financial assistance policies that apply discounts to the amounts charged. More information on our financial assistance policies can be found obtained by contacting the hospital financial services department.
Health insurance companies contract with hospitals to care for their customers. Hospitals are paid the insurance company's contract rate, which generally is significantly less than the amount listed on the Chargemaster. The insurance company's contract rate, not the Chargemaster, is the basis for determining the patient's actual out of pocket costs. As an example, a hospital may charge $1,000 for a particular service, while the insurer's contract rate may be $700. If the patient's insurance plan indicates the patient is responsible for 20 percent of the contract rate, the patient would owe $140 ($700 x 20 percent).
ARE CHARGES THE SAME FOR EVERY PATIENT?
The list of charges is the same for all patients. However, the total charges for an individual patient often vary from one patient to another for a number of reasons, including:
•How long it takes to perform the service or how long it takes you to recover in the hospital
•Whether the service or procedure you receive is more or less difficult than expected
•What kinds of medication you require
•Whether you experience complications and need additional treatment
•Other health conditions you may have that may affect your care
IS THE CHARGE THE SAME AS WHAT A PATIENT PAYS?
Chargemaster information is not particularly helpful for patients to estimate what health care services are going to cost them out of their own pocket.
The charge listed in the Chargemaster is generally not the amount a patient will pay. If you have health insurance, the amount you will be billed and expected to pay for your services depends on your specific health insurance coverage and your insurance company's contract with the hospital.
If you do not have health insurance, you may be eligible for reduced costs under the hospital's financial assistance policy, or you may be eligible for Medicaid coverage.
WHAT IS NOT INCLUDED IN THE CHARGEMASTER LIST?
The hospital's chargemaster does not include charges for services provided by the doctor (or doctors) who treat you while you are at the hospital. You may receive separate bills from the hospital and the doctors involved in your care.
Here is a partial list of health care providers who may bill you separately:
•Your personal doctor, if he/she sees you in the hospital
•The surgeon who performs your procedure
•The anesthesiologist who works with the surgeon
•The radiologist who reads your x-rays or other imaging
•Other doctors who may be consulted by your doctor during your time in the hospital
WHERE CAN I FIND MORE INFORMATION ABOUT HOSPITAL COSTS?
If you would like more information about the Chargemaster, what your care will cost you or the hospitals' financial assistance policy, please contact the hospital financial services department.
Please consult with your insurance provider to understand your insurance coverage, which charges will be covered, how much you will be billed, information on deductibles, and your expected out-of-pocket responsibility.
COMMONLY ASKED QUESTIONS
WHAT ARE HOSPITALS DOING TO BE TRANSPARENT?
Hospitals are committed to providing price information to consumers.
- Because of widespread variation in health insurance coverage, it is difficult for hospitals to provide specific cost information without access to very detailed information about a patient's health insurance coverage.
- Hospitals invest heavily to make cost information more accessible by taking measures to make pricing information available to patients.
WHAT IS A CHARGEMASTER?
A Chargemaster is a comprehensive list of charges for each inpatient and outpatient service provided by a hospital - each test, exam, surgery or other procedures, room charges, etc.
- Given the broad scope of services provided by hospitals 24/7, a Chargemaster contains thousands of services and charges.
- Health insurance companies contract with hospitals to care for their customers. Hospitals are paid the insurance company's contract rate, which generally is significantly less than the amount listed on the Chargemaster.
- An individual hospital's charges vary based on its unique range of services, adoption of new medical technologies, government underfunding, patient demographics and other local and regional factors.
HOW IS INFORMATION SHARED WITH PATIENTS AND FAMILIES?
The Chargemaster is not a useful tool for consumers who are comparison shopping between hospitals.
- Our hospital employs financial counselors and other resources to help our patients understand their financial obligations. You may contact the financial services department for assistance.
- We encourage patients to reach out and ask detailed financial questions - especially before scheduled services.
- Our hospital is ready to help patients and their families understand their financial obligations at any time during the treatment process.
ARE CHARGES DIFFERENT FROM PAYMENTS?
Yes, charges are different from payments. Chargemaster information is not particularly helpful for patients to estimate what health care services are going to cost them out of their own pocket.
- Chargemaster amounts are almost never billed to a patient or received as payment by a hospital.
- The Chargemaster amounts are billed to an insurance company, Medicare, or Medicaid, and those insurers then apply their contracted rates to the services that are billed. In situations where a patient does not have insurance, our hospital has financial assistance policies that apply discounts to the amounts charged. More information on our financial assistance policies can be obtained from the financial services department of the hospital.
- Each hospital has different proportions of Medicare, Medicaid, commercial insurance or uninsured patients, which adds to the complicated nature of hospital billing.
- Every insurer pays the hospital differently. Medicare and Medicaid generally pay less than the actual cost of caring for patients.
- There are also patients who, unfortunately, can't pay their hospital bills. Across the country, hospitals treat uninsured and underinsured patients every day.
WHY DO HOSPITAL COSTS OF CARING FOR PATIENTS VARY?
Every patient's case is special and requires different levels of care. Hospitals are prepared with doctors, nurses and high-tech equipment around the clock for illness or injury - from a twisted ankle to a major accident to a natural disaster.
- The price a patient sees on the hospital bill reflects all the people who care for them and keep the hospital operating, not just the services provided, such as:
o Nurses and caregivers at the bedside
o Pharmacists, lab technicians, food service staff, environmental service professionals and security personnel who, among many others, keep the hospital running 24/7
o Specialty care providers
- Hospital costs have many factors, such as staffing, equipment, maintenance costs and the differences in care needed by each patient. Key components of hospital costs that vary by region, community and individual hospital include:
o Services provided for the patient's unique care needs
o 24/7/365 readiness to meet the community's health care needs
oCharity care for people unable to pay
o Medicare and Medicaid underpayments - programs that pay the hospital less than the cost of caring for patients with health coverage through the programs
Link to a helpful video explaining Price Transparency
The information provided below is a comprehensive list of charges for each inpatient and outpatient service or item provided by our hospital, also known as a Chargemaster. It is not a helpful tool for patients to comparison shop between hospitals or to estimate what health care services are going to cost them out of their own pocket. Patients should contact their medical insurance provider to get further details about the possible cost of their care, including healthcare providers in and out of network and services covered. Patients should also talk with their insurance provider to understand which costs will be covered by insurance and which will be the patient's responsibility. Patients without medical coverage may obtain our hospital's financial assistance policy by contacting the financial services department of our hospital. For more information about the cost of your care, please contact our patient financial services department.
The amount listed for each service in the chargemaster is not necessarily reflective of your actual financial responsibility. We recommend that patients contact their insurer or our hospital business office to discuss their individual situations and determine the potential out of pocket cost of their care. Call our business office at (855)453-1211.
For more Chargemaster information CLICK HERE