How much will that cost/did that cost? Part 1 of a series on billing

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SUMMARY: How much will that cost? Why did that cost so much? People are getting used to asking this in the health care marketplace. Many of us grew up with the $10 co-pay, but that’s rapidly becoming a thing of the past. With rising deductibles, more out-of-network providers, more uninsured people and more out-of-pocket spending, it’s increasingly a question we want to ask – and before the medical procedure, not after, when the “gotcha” bill upsets us. Here’s a handy guide to asking: Before, during and after. How much will that cost? Why did that cost so much?

The last time I wrote about this, the piece was  posted on the blog at credit.com, where I am a contributor. But that was three years ago, and a lot of things have changed. So I’m updating that post with new information.

The first thing we recommend, in every case where you have an option to go someplace else: Ask what the cash price is.

Increasingly, we are hearing from people who are paying much less in cash than they did using their insurance cards. Sometimes it’s even thousands less, when all is said and done. So in every case, ask. Ask the provider. Ask several providers, so you can have a sense of whether the provider is charging a lot or a little.

Here are a couple of my blog posts about that, here and here, and here’s a Wall Street Journal article about the same thing.

One effective strategy: I read recently about a person who asked in advance about the cash price for a discretionary surgical procedure. Then he had the procedure and came out — to find an insurance payment that took care of part of the bill, while he was asked to pay more. The insurance payment pretty much covered  the cash price he’d been quoted — and he was being asked to add even more money.

He called the billing office with his information, and the extra bill, supposedly his responsibility, went away.

We also know of providers in the same city or town who will accept wildly varying cash payments.

So: Always ask. Take notes, take names, take numbers.Ask “What is the cash or self-pay price?” “What will I pay with my insurance?” You might be surprised.

Routine vs. emergency care

As always, we remind our readers that we don’t give any kind of medical advice.

In thinking about this “find out ahead” question, we distinguish between two general kinds of treatment: routine care (preventive checkups, the garden-variety strep infection, etc.), and emergency care or other big-ticket medical events like crisis appendectomies. The first group is fairly easy; the big-ticket stuff, less so, though you can do some things to help yourself.

When you’re insured, you have to deal with factors like these: have you met your deductible? Does your plan require pre-approval? Is your provider in network or out? So indeed it can be complicated. But we’re hearing more people asking for cash or self-pay prices, negotiating surgical fees and being thoughtful about purchasing. In our partnerships with public media, we hear from insured people who say things like this:

  • I asked the hospital and they said the X-ray would cost $720. I went to another provider, and it was $30.
  • I asked the insurer’s web site what I would pay, and also asked the provider. Neither could tell me much that was useful. So I used the ClearHealthCosts information I found on WHYY’s website, and saved $1,205 from what the insurer told me.

If you’re insured, ask your provider or check the company’s website for pricing tools. Many insurers now offer them, though some of them are really bad. Here’s an article from one of our partners about that.

Some states have pretty good pricing tools, such as Minnesota and New Hampshire, but a lot of the state resources are not so great. In Ohio, for example, the prices are simply the list or “chargemaster” prices, which are the top-end rates, and thus not very useful. The National Conference of State Legislatures has a scorecard of those resources.

Here are some easy steps to find out what things cost.

Routine or Non-Emergency Care

1. Find out the exact name of the procedure, and how it’s referred to in the medical billing system, referred to as Healthcare Common Procedure Coding System (HCPCS) or CPT (Current Procedural Terminology) codes. These codes categorize the mind-numbingly huge number of medical procedures that go through the nation’s billing system. There’s often a five-digit code: for example, a simple MRI of the lower back is coded 72148. To find the procedure name and number, ask the provider, and/or use the search box on the front page and other pages of the clearhealthcosts.com site: type in “MRI” and pick from the choices offered. If there’s something you don’t understand, ask the provider: “Is that a 72148 MRI or a 72156?” The ICD code is of less value here. (Read more about the codes here.)

2. Use the search box on our front page to find out the price paid for that procedure by Medicare in that provider’s locale. The Medicare price is the closest thing to a fixed or benchmark price, and there’s a byzantine formula for determining that price. For a 72148 MRI, for example, the Medicare price in Manhattan is $497. The search box will helpfully supply a code if you don’t know for sure. We also tell you our survey prices, and some crowdsourced prices, mostly in the 11-12 metro areas we focus on (New York, Los Angeles, San Francisco, Philadelphia, Miami, Tampa-St. Petersburg, northern New Jersey and four Texas cities: Dallas-Fort Worth, Houston, San Antonio and Austin). This search isn’t perfect, but it’s pretty good. (If you find bugs, let us know at info@clearhealthcosts.com.)

3. Now it’s time for a little spadework. There may be several providers in your area who do the same procedure. Ask two or three to quote a price. And, depending on the procedure, there may be several elements – say a colonoscopy, which might include the doctor, the anesthesiologist, the pathology charges, maybe even a “facility charge” for the building where it all takes place. So ask about each of them (for pointers, go to our blog page and use the search box to search the procedure; we have a growing list of blog posts about things like “colonoscopy” or “sleep study” or “gall bladder removal” or “childbirth”). We often hear of people encountering out-of-network anesthesiologists, emergency-room docs and even pathologists … not to mention the ambush “facility fee.” Ask “Do I need a consultation?” “Is there a fee for reading the results?”  or “Can you confirm that’s an in-network anesthesiologist?” or “Are there any other fees I need to know about? Take names, take notes, take numbers.

4. Are you uninsured, or is it not covered by your insurance? Then ask for a cash or self-pay price.  Quite often, providers will offer a discount if you pay upfront, in advance — not just for discretionary procedures like Botox and Lasik eye surgery, but also for things like an MRI, a mammogram or an ultrasound. We hear a lot from people who are asking to pay the Medicare price, or something close. The first price that is quoted, we often find, is a “chargemaster” or sticker price – like an MSRP in electronics. Depending on where you live, you might be entitled by law to a much lower price. In California, for example, discounts off the sticker price must be given to uninsured or underinsured patients below a certain income level. Ask if there are any price breaks. Then ask again.

I did this recently for an eye  exam for what seemed like a routine infection. The cash or self-pay price was $200. The provider said I’d be paying a $50 copay. The insurer said the remainder of the “negotiated rate” — the insurer’s contracted price with the provider — would be my responsibility.

The insurer’s “help” line person said she didn’t know the negotiated rate, but I should call the provider and they would know. The provider’s billing office person said she didn’t know. I asked again and again — and they put me on hold, then returned with the information that the negotiated rate for that insurance policy for a new patient (I hadn’t been there for a while, so was considered new) is $100.

5. Are you insured? Is it covered by your insurance? Ask “Is Dr. X in my network? Is it covered? What’s my co-pay? Am I required to pay a percentage?” Ask if the price being quoted to you is the chargemaster or sticker price — or if it is the “negotiated rate,” negotiated by the provider and the payer (in this case your insurance company). Know your plan: Have you met your deductible? Is this something your plan doesn’t cover at 100%? Ask, and keep asking.

You may need to ask both provider and insurer; you may have to ask for “pre-authorization” to assure it will be covered. Know your policy. Take notes. Take names.

One catch we’ve heard: A person who had an MRI authorized by the insurance company, which then declined to pay — saying that authorization and consent to pay are different things. Gotta love the insurance company when it splits hairs like that.

6. If you think the prices are high, you may be right. Hospitals generally charge more for things like an MRI than a self-standing radiology center does. If your provider is offering a $2,300 MRI, you might feel comfortable asking if you could go to the place up the street that charges $500. As we said before, ask around.

7. Keep a record of who you talked to and when, what they said, and how to reach them again. We have heard many times that people asking these questions get several different answers from different people.

8. Check online resources. Our site at clearhealthcosts.com is part of a growing ecosystem of transparency tools. We can tell you the Medicare reimbursement rate; we also collect cash or self-pay prices in those 11-12 metro areas for 30-35 common, “shoppable” procedures. In San Francisco, for example, an MRI of the lower back (code 72148) can be obtained for cash for $475 or $6,221. If your insurer wants you to pay $2,000 for that, you might think twice.

We also have a separate database for bigger-ticket items. Because the methodology for collecting the data is different — we scooped it up online, or asked providers for lists, and the procedures don’t match with the CPT codes used in the rest of the system — we have kept the two databases separate.

Also, a cautionary note: We do not guarantee these prices. We collect them in a journalistically representative survey. We do not attempt to be exhaustive or comprehensive, surveying every provider in a marketplace. Also, we do not profess to be up-to-the-second: the marketplace is full of mergers and acquisitions, and so owners may change, prices may change. A physician practice may be acquired by a hospital, or it may merge with another practice.

Some other tools: healthcarebluebook.com (gives a “fair price” based on your location); fairhealth.org (price information for consumers and businesses); Guroo, which is funded by and uses information from, the insurance industry, also has one price for your locale. We are not fond of the “one number” solution, because it does not seem actionable to us: Can you go into the MRI provider and say “Guroo says the average price in New York is $504, so I’d like that price”? Probably not.

Several others, like MDSave.com, have prices, and talk about transparency. But remember, a place like MDSave, a venture-funded company, will almost certainly be charging more than a cash rate — because they have to pay back the venture capitalists who funded them. Also, many of the online resources will ask for your email and other information; if so, it’s possible that they plan to charge you or somehow reap a commission-type payment for sending you to a certain provider.

With online shopping resources, some rules of thumb:

  • We are fond of our methods and our data. We’re journalists, and we’re not sending you to providers in order to earn money off your choices
  • We know, of course, that other online shopping resources exist. We suggest that people try several and compare results. And let us know what you learn!
  • When you do that, ask yourself: Why do these results differ? Where is this site making its money? Can I confirm this information by phone? if Guroo is funded by the insurance industry, does that mean their results are impartial and accurate? Does MDSave make money by sending me to providers it does business with? Did an online resource ask for information about me before it gave me any meaningful information?

What if it’s not routine? Walk-in and emergency care

We do not give any kind of medical advice. We talk only about the money, and give ideas of what stuff might cost and how to navigate the system.

You’re not likely to be shopping around if you’re in an ambulance with a broken leg, or unconscious on a gurney. But there are things you can do to make smart choices about emergency care.

First, if you’re insured, know the hospitals close to you that are in network (for your plan) that will be your ER of choice in case you or a family member needs crisis care. When my kids were little, I kept the directions and the information on the “emergency” sheet on the fridge.

But also – and this is new for many of us – a walk-in or urgent care center may well be a better choice. (Remember, we don’t give medical advice here.) Walk-in centers tend to be much less expensive than full-blown hospital emergency rooms. Many of us routinely took croupy kids to emergency rooms in the middle of the night, but that’s changed in a big way.

It’s even possible that your insurer will encourage you to go to a walk-in center by giving you a standard co-pay for a walk-in center on your insurance plan — a way to suggest to you gently to stay out of the emergency room, where costs can start high and skyrocket from there.

A fast-growing option

Walk-in centers of all kinds are the fastest-growing part of the medical marketplace. They range from pharmacy and big-box clinics (Dr. Walk-In at Duane Reade, The Clinic at Walmart) to Concentra, a big chain with more than 300 clinics in 39 states, to smaller chains like CityMD, based in New York.

If your problem is a sore throat, a urinary tract infection or a croupy kid, your first choice is likely to be your doctor — if you’re insured and you have one.

But if you’re uninsured or can’t get to your doctor quickly or easily, this is another option. It’s not a bad idea to call around just to know providers near you.

Not all walk-in centers are created equal. Some are staffed by nurse practitioners, by emergency room doctors, by owner-operator doctors or by a pharmacist.Some call themselves “urgent care.” Some may not take people with gynecological issues, or gaping chest wounds or broken bones. It’s worth knowing the territory to save yourself time, trouble and money.

Walk-in centers may not feel comfortable quoting a price in advance, because the price can depend on treatment: Do you need lab tests, X-rays, a cast? So you might inquire: Do you take my insurance? What kind of cases do you treat? What is the charge for a basic office visit? What are your hours? What’s the charge for a cash visit for a sore throat if you’re uninsured?

Increasingly, these walk-in centers are posting price lists. Also often posting price lists are “direct-pay” doctors and primary care centers. Of course it’s not possible to predict how many tests or treatments will result from a walk-in visit for a sore throat, but on some level some of these are predictable.

We survey providers on their walk-in clinic visits in our 11-12 major metros. Use the search tool on our site to search just that — walk-in visit — to see the range of prices. Here’s a list within 100 miles of a common New York City zip code. (If they won’t give us a price when we survey them, we put $0 in the database and add the note “no prices over the phone.”)

So, about price lists: Here’s one for the Dr. Walk-in centers at Duane Reade/Walgreens. Here’s one for the Minute Clinic at CVS. Here’s a list at the Walmart clinic site. Here’s a price list from one direct-pay practice, Neucare, in Lawrence, Kan. If you’re looking for direct pay in your area, try Googling.

Ask around: The wisdom of the crowd

Ask friends and neighbors for their experiences. Social media can help: in my village, we’ve got a “Moms” Facebook page where people share recommendations for gynecologists, primary-care providers and the best place to take a croupy kid on the weekend.

Also, beware of the rising trend toward free-standing emergency rooms, which are separate from hospitals. They present what appears to be an attractive alternative, but the word on the street is that they can be expensive.

And if you’re in an emergency situation and still able to ask, do yourself a favor: Make sure that all the providers you see are participating providers. We hear a lot about people who receive bills telling them that they were at an in-network hospital with an in-network doctor and in-network pathology, but the anesthesiologist was out of network and therefore the bill blows back on them. Insist that you want an in-network provider.

How much will that cost? Always ask.

Part 2: Appealing a claim.