How Policy and Technology Bring Price Transparency to Patients

A few years ago, my doctor referred me to the nearby hospital he was affiliated with for an imaging exam. I was given a script and instructed to contact the hospital for scheduling.

Having worked at an outpatient imaging center in the past, I knew I had options when it came to medical imaging—specifically, whether to go to the hospital or an outpatient imaging center. And my experience in medical informatics has taught me that health insurance coverage is complex, and I should find out what something costs before I schedule my appointment. So I started my search.

1. I contacted the hospital to find out what it would cost me for the exam. They advised me to contact my insurance company.
2. My insurance company informed me that I needed to get the Current Procedural Terminology (CPT) code from my ordering physician.
3. I contacted my ordering physician’s office, which gave me the CPT code.
4. After reconnecting with my insurance company, I was informed that they also needed the International Classification of Disease (ICD) code, i.e., the reason for the exam.
5. I contacted my ordering physician’s office, which gave me the ICD code.
6. After calling my insurance company for the third time, they let me know I would owe my full deductible of $1500 at the time of the exam, and then they would cover a percentage of the rest of the charges. They then advised me to contact the hospital to find out the total cost.
7. Once again, I contacted the hospital and gave them the CPT and ICD codes. Only then was I able to find out that the total cost to me would be $1560 for the exam.

As mentioned, my professional experience meant I knew about contracted insurance rates and service-based locations, and the significant cost disparities that can come with them. So I contacted my local outpatient imaging center to learn what the cost would be to have the imaging done at their location. Total out-of-pocket cost: $50, a more than $1,500 price reduction from the hospital’s estimate, all because of the type of service and contracted rate with my insurance provider.

I know I’m the outlier in this situation. Most patients don’t realize they have options when it comes to price shopping for healthcare services, nor do they have the time to track down the information needed to ensure they’re making the best decision for their care and their wallet.

Thankfully, with the rise of consumerism of healthcare, we’ve started to see a shift in mindset. For example, earlier this year, the Centers for Medicare & Medicaid Services (CMS) enacted the No Surprises Act, a federal protection against “surprise medical bills” that often arise when insured consumers inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose. Additionally, if a consumer is uninsured or doesn’t plan to submit a claim to their health plan, providers and facilities must now provide a good faith estimate of expected charges prior to service. Policies such as these are bringing price transparency to healthcare, but technology can play a similar role.

But perhaps most importantly, leveraging technologies such as Synapse EIS builds patient trust, and in today’s consumer-driven world, that’s priceless. To learn more about how Synapse EIS can benefit patients and practices, click here.