How to Know the Cost of a Medical Procedure

How much will that cost?

It’s a question consumers aren’t used to asking 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.

So, how do you find out what things cost in the health-care marketplace?

First, let’s distinguish between two groups: 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? Are you 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 (a friend just negotiated a $40,000 fee down to $10,000) and being thoughtful about purchasing.

If you’re insured, ask your provider or check the company’s website for pricing tools. Many insurers now offer them, though not all are extremely useful.

Some states have terrific 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 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, or try the search box on 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?”

2. Find out the price paid for that procedure by Medicare in your 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.

3. Now it’s time for a little spadework. There may be several providers – 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. We often hear of people encountering out-of-network anesthesiologists, emergency-room docs and even pathologists … not to mention the ambush “facility fee.”

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.

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.

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.

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 at the same provider or insurance company.

8. Check online resources. Our site at clearhealthcosts.com is part of a growing ecosystem of transparency tools. Some of the others:

healthcarebluebook.com (gives a “fair price” based on your location);
fairhealth.org (price information for consumers and businesses);
newchoicehealth (offers generally high prices, then invites users to connect with featured providers or request a bid);
faircaremd.com (offers a range of provider-supplied prices and an opportunity to negotiate).

Emergency Care: Walk-In Center Before Emergency Room

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 on your plan that will be your ER of choice in case you or a family member needs crisis care.

But also – and this is new for many of us – a walk-in center could be a better choice. 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.

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 mini-chains like CityMD 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.

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?

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 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.

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. Use those resources.

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.

Image: iStockphoto