How to Shop for Price Transparency in Healthcare

Healthcare can be expensive. Learning how to shop for price transparency in healthcare can help you make the best decisions — for your health and your budget.

Understanding how to shop for price transparency in healthcare can be an important way to save money and avoid, when possible, so-called “surprise” medical bills (called balance billing).

When it comes to shopping for health insurance, it’s not difficult to find out what a policy will cost each month, as well as what your deductible (the amount you pay for covered medical services before your insurance plan kicks in) and co-pays for services will be. But that isn’t the whole story when it comes to the cost of healthcare.

Knowing exactly — or almost exactly — how much you will be charged for medical tests, treatments, procedures, and doctor visits is rarely easy, whether you have health insurance or not.

Although more price transparency from hospitals is slated to be required by the federal government, starting in 2021, you still need to do your own research when it comes to unraveling medical costs. And it’s helpful to know what’s behind healthcare charges and why they can differ from provider to provider, so you can have a clear idea of what you are paying and how to potentially save money (and save for possible upcoming healthcare costs).

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A case in point: When you go to an in-network healthcare provider, after you’ve paid any co-pay and reached your deductible, your insurer pays the negotiated amount the insurance company has worked out with your provider. But, if the provider charges more than the negotiated fee, you may be charged the balance. And if you go out-of-network, even unknowingly (for example, if a non-network expert is called in by your in-network doctor to consult on your case), you will likely be hit with a costly and unexpected bill.

What’s more, if you are uninsured, or between insurance providers due to a job change, you may be able to receive care at a deep discount by paying cash. Paying cash may also be your best option if you have a very high-deductible insurance policy, too. However, you likely won’t be offered information about a cash rate, unless you ask.

In fact, rates insurers negotiate with providers and cash payment rates are seldom made public. So, when it comes to how to shop for price transparency in healthcare, you need to ask specific questions and be persistent. But it can be well worth your time.

Look: Steps to get information about healthcare prices

In 2021, a federal rule promoting price transparency in healthcare goes into effect. It requires hospitals to share price information, which is currently difficult for patients to access, including the payment rates hospitals negotiate with insurance companies for procedures in the hospitals as well as “shoppable services,” such as lab and imaging tests, which can be scheduled on an out-patient basis. Hospitals will also be required to reveal discounted fees they offer patients who pay cash.

What’s key for patients is that all this information about medical fees must be easily accessible, understandable, and easily found online. But for now, until the federal rule goes into effect, how you shop for price transparency in healthcare involves being proactive.

Strategies for shopping for healthcare

• When shopping for a health insurance plan, make sure you understand the policy’s deductible and co-pays and look carefully at an insurer’s network of providers. See if the in-network doctors and hospitals are convenient for you and your family and if they include physicians and facilities you prefer for your care. You can take this information and compare it among several insurers as you consider the best healthcare for you financially, as well as medically.
• Unless you have a health emergency, contact your insurer, doctor, and hospital before you undergo tests and treatment and ask for up-front estimates on your costs. Although it’s not unusual for some healthcare providers and insurers to refuse this request, it’s worth the try. And, the Wall Street Journal reports, an increasing number medical facilities and doctors will agree to an estimate for planned procedures. With this information, you can shop at several in-network providers to compare projected costs.
• Ask specifically if a health plan pays a provider who is not in network and, if so, what percentage, the Healthcare Financial Management Association (HFMA) advises.
• Another important tip for shopping for price transparency in healthcare: Be aware that even if you are having surgery or another procedure at a confirmed in-network hospital, under the care of an in-network surgeon, you may not be informed an anesthesiologist, pathologist, or radiologist involved in your case is out-of-network. The result could be a “balance bill,” potentially for thousands of dollars you didn’t anticipate, for the difference between your insurer’s payment and the total charge from the non-network specialist. How do you prevent this? Talk to your doctor and insurer before your procedure, if possible, and specifically ask for only in-network specialists to be involved in your case.
• You can’t always plan ahead for emergencies, but it makes financial sense, when shopping for price transparency in healthcare, to check with your insurer on the emergency department facilities nearest your home and place of work that are in-network.
• When you need to have a procedure or treatment, take time to check with both your healthcare provider and your healthcare plan to make sure the medical facility and your doctor are still in-network. Agreements between health plans and physicians and hospitals can change, the HFMA cautions. Just because a doctor was in your healthcare plan a year ago doesn’t absolutely mean that’s still the case, and assumptions can be expensive when it comes to the price of healthcare.

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