Hospitals frequently utilize the chargemaster price as a starting point in talks with private insurers, although market forces ultimately determine the agreed-upon pricing. Medicare and Medicaid pay hospitals a government-determined rate that does not take into consideration a hospital's chargemaster pricing. The remaining patients, who can afford to pay out of their own pockets, rely on what has become known as the "chargemaster" system to determine how much they will have to pay.
These days, there is almost no escape from being charged something. Even uninsured patients may be required to pay up to an estimated $1,000 if they fall ill with a very expensive condition like cancer or heart disease. And even if they cannot pay, they may still be forced to borrow money from loan sharks at high interest rates or accept treatment that will leave them disabled.
The charge for an operation or other procedure begins when a physician orders it. For example, a surgeon might order a liver transplant by writing a prescription for a donor organ. When the patient goes to get the organ, however, the hospital won't perform the transplant without first getting paid. The hospital charges the doctor for the service performed during the transplant surgery, which in this case is the removal of the liver and replacement with a donated organ.
The hospital also bills insurance companies on the chargemaster rate, regardless of whether the patient has insurance or not.
Insurance companies, hospitals, and doctors usually bargain over the cost of each medical treatment. The government establishes a predetermined fee for each surgery that people may undergo. It does not bargain with doctors and often pays cheaper prices than private health insurance. Each hospital sets its own price for services, sometimes without consulting physicians. Doctors can charge what the market will bear.
The way insurance companies pay for medical treatments affects how much they pay in total for healthcare. If they pay on a per-service basis, then they will only pay for what amounts to a fraction of each procedure. If, on the other hand, they pay on a capitated basis, which is common in Medicare for example, they will have covered the overall cost of providing care to their members even if it means paying more per service.
Hospitals also set their own prices. They do this by looking at the number of different procedures patients receive and applying an average cost per procedure to those that perform them most frequently. For example, if half of a hospital's patients require knee replacements and the average cost of these surgeries is $10,000, then the hospital can estimate that setting a single price for all knee replacements would result in a loss. Instead, it offers lower prices to those who need multiple replacements because the overall cost of treating this group of patients is lower.
Insurance companies cover hospital bills at a reduced rate. The amount of the discount varies per insurance company. When the insurance company pays its half, the reduced amount (adjustment) is deducted to represent the patient's real obligation (co-insurance). If the patient cannot pay his or her share of the bill in full, then the insurance company can request that the patient pay a partial amount (deductible). As long as the patient meets this deductible requirement, all of the remaining balance is his or hers to use as he or she sees fit.
When a patient arrives at the emergency room without insurance, they are responsible for all costs upfront. Emergency rooms usually have a list of local resources that patients can access if they are unable to pay their bill in full. If a patient has the ability to do so, they should try to resolve their issue with their primary care physician before arriving at the ER. This will help keep costs down and get them into treatment faster.
It is important to know your insurance coverage limits. For example, if you have hospital indemnity insurance, there may be a limit to how much it will cover each year. If you exceed this limit, you could be on the hook for any excess charges. In addition, some policies also have a limit on how much can be spent on medical services during an annual visit.