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It is important to note, a hospital “charge” is not the same as “expected payment.” A charge is the amount billed for a service. In the vast majority of cases, hospitals are paid considerably less than the billed amount. Hospital charges are based on the type of care provided and can differ from patient to patient for the same service. The differences between patients are related to complications or varying treatments needed due to the patient’s health.
Even though the hospital’s prices on our list are the same for all patients, actual charges for each specific patient may vary from the listed standard charges due to a combination of factors.
CMS Pricing Transparency Rule Summary
The finalized rule from the Centers for Medicare and Medicaid Services (CMS) establishes requirements for hospitals operating in the U.S. to establish, update, and make public a list of their standard charges for the items and services they provide. These actions are necessary to promote price transparency in healthcare and public access to standard hospital charges. By disclosing hospital standard charges, CMS believes the public (including patients, employers, clinicians, and other third parties) will have the information necessary to make more informed decisions about their care. CMS believes the impact of these policies will help increase market competition and ultimately drive down the cost of healthcare services, making them more affordable for all patients. This final rule is effective on January 1, 2021.
In accordance with the regulation, Sierra Medical Center is required to make its list of standard charges for all items and services publicly available online in a machine-readable file, and provide a consumer-friendly display of at least 300 shoppable services.
The Price Estimator Tool provides a consumer-friendly display of standard charges for at least 300 ‘shoppable’ services, including the 70 services mandated by CMS and at least 230 more services commonly scheduled at our facility. Healthcare consumers can use this Price Estimator Tool to obtain an estimate of the amount they will be obligated to pay for a shoppable service. Please consider the following when using this Price Estimator Tool:
- Charges are current as of January 1 of the current calendar year.
- Price estimates are not a guarantee of third-party reimbursement or coverage and are subject to change at any time due to a variety of reasons, including complexity of case, severity of illness, additional services utilized, and more.
- Price estimates do not include physician charges or charges for services rendered by providers other than the hospital.
- Patients could also call the hospital directly to discuss estimates specific to amounts potentially owed (e.g., deductibles, copayments, and coinsurance balances).
The file provided below displays the standard charges for items and services that may be offered by Sierra Medical Center. Please consider the following when using this file:
- We strongly encourage patients shopping for services to use the Shoppable Services Price Estimate tool or contact their health insurance provider to determine applicable benefit limits and out-of-pocket costs. Patients could also call the hospital directly to discuss estimates specific to amounts potentially owed (e.g., deductibles, copayments, and coinsurance balances).
- This file does not account for all financial assistance or uninsured/underinsured discounts that are available to eligible patients and does not facilitate the calculation of other patient responsibility amounts, which vary by patient and visit type.
- Payers might not reimburse for each service or item using the same methodology, which inhibits comparison between payers for those services and items without applying rate structures related to specific patient stays. Rates provided do not account for outlier reimbursement, carve-out services and items, add-ons, and rate structures related to specific patient stays (e.g., length of stay). Based on negotiated contractual agreements, payers might also adjust the reimbursement listed in this file based on value-based or quality-based assessments.
- This file does not include charges for services not provided by the hospital or charges billed for non-hospital services, such as the provider’s professional fees. Only prices for negotiated services and items are included in this file. Gross charges, cash prices, and negotiated rates either not reimbursed or not separately reimbursed by the applicable payer are represented by a “-1”.
- Some payers market a variety of plans (e.g., HMO, PPO, MA, etc.), and in cases where reimbursement between plans differs, those amounts are provided separately with each plan identified. In cases where reimbursement is not plan-dependent, the contracted reimbursement amounts are presented as a single data set identified by the payer.
- Gross charges are not provided for non-chargemaster items (e.g., DRGs) because there is no fixed gross charge amount. Patients with the same DRG might have significantly different charges based on severity of illness, services rendered, and other complicating clinical factors. Since our cash price is based on a percentage of gross charges, it cannot be provided for these items because it does not exist.
- While negotiated rates are provided for chargemaster items, many are not separately reimbursable when billed in association with a procedure paid at an all-inclusive rate, even when a charge amount is listed. This is common for supplies and drugs that are packaged in reimbursement, which make up a significant amount of the overall chargemaster line items.
- Charges, minimums, and maximums are provided for payers with negotiated rates. Typically, negotiated rates for managed Medicare/Medicaid payers are benchmarked against government payer reimbursement, which might be less than commercial reimbursement. Therefore, these rates should not be compared.
- In some situations, contract terms establish reimbursement based on a specific methodology or billing code, even when multiple methodologies or billing codes might apply. For example, an inpatient nursery stay for a newborn baby is often reimbursed by revenue code, not MS-DRG/APR-DRG, even though negotiated DRG rates exist for that service.
- In some cases, reimbursement might be capped to a maximum of billed charges regardless of the negotiated rates. Additionally, charges measured in increments (e.g., hours, milliliters) might be reimbursed based on a fixed amount that’s not directly proportional to the quantity billed.
- Rates and applicable payers are subject to change. As new contracts are negotiated and rates are updated, this file is regularly updated and maintained. This data is current based on the date indicated in the file.
COVID-19 Diagnostic Tests
The Coronavirus Aid, Relief, and Economic Security Act (CARES) requires providers to make the cash price for COVID-19 diagnostic tests publicly available on its website.