The Center for Medicare & Medicaid Services (CMS) is requiring hospitals to post certain pricing information publically to help patients shop for medical services. Please understand that Franklin Medical Center is committed to meeting all Federal requirements, and is working diligently to meet these requirements, but not all this information is available yet. We are posting a preliminary schedule, and will revise it as more information is gathered.
While the government’s goal is for a patient to be able to shop for services based on price, virtually no patients pay the prices charged.
- Medicare and Medicaid set rates that participating healthcare providers must accept.
- Insurance company contract with hospitals to pay based on the insurance company fee schedule. A hospital may have many insurance contracts with different fee schedules, and the only one that matters to you is the one for your particular insurance plan.
- The Affordable Care Act requires that uninsured patients cannot be required to pay more than the amount generally collected from insurance companies. This means if you have no insurance, and are responsible for paying your entire bill, you will not pay more than insurance companies generally pay.
All this makes healthcare pricing very complicated.
FMC believes our patients should understand what they are responsible for according to their individual health insurance plan. As such, we are working to implement an out-of-pocket estimation tool that is based on your health insurance, which will be much more meaningful than the information presented here. When that cost estimation tool is implemented it will replace information presented here.
FMC billing department is available at 318-412-5290 or 318-412-5412 to assist you in understanding the amount you owe. We can help you in any of the following ways:
- Understanding the “Explanation of Benefits” your insurance company sends to you when they pay a bill; or
- Financial Assistance – You may apply for financial assistance based on FMC’s voluntary policy that allows discounts based on your income compared to Federal Poverty Guidelines or your total medical bills compared to your income.
The bottom line: We urge caution when looking at FMC, or any other providers publically posted cost estimates. There are many factors that determine the final amount that will be paid from a health plan to a provider, and there is no way to capture all of those factors in a single set of numbers.
HOW TO READ THE REPORT
When reviewing this information you will need to understand the following column headings:
Required List from Regulation – this is the list of 70 items required by CMS
1 Plain Language Description – this is a more patient-friendly description of the required items, and for the items we added to the list it is the FMC billing description.
1a Also Known As – Another description field to help you identify the item
2 Offered (Y/N) – Is the service offered at FMC, Yes or No (some services on the CMS list are not)
3 Payer Specific Negotiated Charge – Required by CMS, but we are still accumulating this information from our insurance contracts
4a Discounted Cash Price – FMC allows uninsured patients a 40% discount to insure that individuals do not pay more than insurance companies, as required by the Affordable Care Act. This is the price uninsured patients will be responsible for.
4b Gross Charge – This is “list price” used to calculate negotiated discounts.
5 and 6 Negotiated Minimum and Maximum Charge – Once all the fee schedules are accumulated for column 3 we can identify the lowest and highest charges.
7 Location – This is the FMC location where the service is provided. This is important, as you will notice for example one specific code may be offered in higher cost and lower-cost settings, so that different prices are charged (for example Primary Care Clinic vs. Specialist Clinic). For items and services offered to Hospital inpatients (IP) or Hospital Outpatients (OP) all patients are charged the same price regardless of the location of the patient. For example a Lab test performed in the hospital lab is the same for all patients, whether patient came from a Clinic, the Emergency Room, or an outside physician office.
8 Primary Code – This is an identifier to help define exactly the procedure listed. These are generally CPT codes or Medicare DRG codes. The American Hospital Association defines CPT (Current Procedure Terminology) codes, and those codes are used by Medicare, Medicaid and Insurers to specifically identify procedures. A DRG (Diagnosis Related Group) code is a Medicare listing that groups and pays for inpatient services by diagnosis.
The 2 columns on the far right are additional information you need to know to assess the total cost of a procedure. Healthcare prices are broken into 2 major categories – Technical fees are the hospital portion and Professional Fees are the physician or nurse practitioner portion. Prices referenced through column 8 are for the Hospital Technical Fee. The last 2 columns on the right refer to the charge for the Professional Fee. Examples of professional fees are:
- Radiologist fee for reading an X-ray, CT or MRI;
- Clinic office visit;
- Fee for Surgeon to perform a procedure in the operating room; and
- Emergency Room Physician fees.
Note that in some cases a clinic service may show a Technical Fee and a Professional Fee. This is due to how Medicare pays for these services. If you do not have Medicare the fees are added together and billed as one Professional Fee.
Cash – The discounted cash price, similar to 4a above, gross charge less the 40% uninsured discount.
Gross – “List Price” similar to 4b above.
The required listing can be viewed here.Price Transparency List