The South Carolina Hospital Association (SCHA), working with AnMed Health and other health systems in the state, has a new website to help consumers better understand hospital pricing.
Called South Carolina PricePoint, the site allows members of the public to access information about services and charges at hospitals throughout the state. Although the site lists "chargemaster" prices for hospitals, it does not show the price most patients actually pay.
South Carolina citizens now have access to information about hospital charges including comparative data that previously has not been readily available.
Although consumers and health systems are concerned about the cost of medical care, studies show that consumers are even more concerned about the quality of care and safety. AnMed Health has made patient safety a top priority for years and the results are evident in projects such as Hospital Compare.
Frequently Asked Questions
How much do I really owe?
Every insurer, whether Medicare, Medicaid or commercial, pays the hospital differently and shares the cost with the patient differently. In fact, the kind of health coverage you have is a major factor in determining what you will pay for your care. If you have commercial insurance, contact your insurer to confirm your coverage and your share of the costs. Your share will depend on your specific health care policy and any out-of-- pocket costs you have already paid during the year. Also, many commercial insurance companies negotiate discounts with individual hospitals that are not reflected in billed charges. To take advantage of these discounts, you must use providers that are in your insurer’s preferred network of providers.After your insurance company has reviewed your hospital bill and paid its portion, the hospital will bill you for your part of the bill. Most insurance plans require patients to pay part of their hospital bill. If you have questions about your insurance, please contact your insurance company.
How do I know if my providers are “in-network” or “out-of-network”?
If you don’t know, check with your insurer. Out-of-network hospitals and other providers have not been able to negotiate a discounted price with your insurer, thus making you potentially responsible for higher personal payments. In fact, some insurers require enrollees to seek care exclusively from a specific list of hospitals and physicians under contract with the insurer for the service to be covered. Consumers who choose a provider that is “out-of-network” may even be responsible for the entire charge. Even if your hospital is in-network, you may receive care from an out-of-network physician. If possible, always find out if all physicians who will treat you are within your health plan’s network. This includes but is not limited to anesthesiologists, pathologists, radiologists or consulting doctors. If they are not within network, ask if they will accept in-network payment for services provided to you. If you’re concerned that your doctor may be out-of-network, contact your insurance company.
What if I don't have insurance?
If you are uninsured and need hospital services, it is important that you contact the hospital billing office. They can help determine if you qualify for government-sponsored assistance. Depending on your income, you may also qualify under the hospital’s financial assistance policy for discounts and even free care. Payment plans may also be available to help you pay for your care.
Consumers can also find health insurance on the www.healthcare.gov website created by the Affordable Care Act. Depending on your income, you may qualify for tax credits to help pay your premiums. While there is an open enrollment period each year during which anyone can sign up for coverage, under some circumstances persons may quality to purchase insurance coverage at other times of the year.
Hospitals can also refer you to someone who can help you navigate www.healthcare.gov and determine if it’s the right option for you.
What is the difference between Medicare and Medicaid?
Medicare is a federal health insurance program for people age 65 or older or under 65 with certain disabilities or conditions.
Medicaid is a joint federal and state program that helps with medical costs for people with low incomes.
If you have Medicare or Medicaid, the government sets the payment rates hospitals and other providers will be paid for your care. Those rates generally do not cover the full cost of the care provided. As with commercial insurance, there may be some out-of-pocket costs.
If you have government sponsored care, you can get more information on the Medicare website (http://www.medicare.gov) or the SC Medicaid website (https://www.scdhhs.gov).
Why do hospital charges vary so much?
Each patient is unique, requiring treatment that meets his or her individual needs. A patient with complications, such as diabetes and heart disease, may require more intense services, staff time, and a longer stay in the hospital than a patient without complications. Another variable is the individual physician providing each patient’s care. A physician’s treatment protocols are based on his or her education, training, experience, and specialty. Therefore, it is not surprising that one physician’s treatment of a patient can vary widely from another physician’s treatment of a patient with similar symptoms.
Charges may also differ between hospitals based on a number of factors. For example, if the hospital treats a large number of uninsured and government sponsored (Medicaid and Medicare) patients, its overall charges are likely to be higher. That's because the hospital is paid less than the actual cost of caring for those patients. To minimize those losses, the hospital has to add the unpaid costs back intoits overall charge structure.This results in insured patients subsidizing the care of uninsured and government-sponsored patients.
PricePoint provides information on the mix of payers representing each hospital’s patient population, as well as the percentage of billed charges paid by each payer type.
Other factors that impact charges include the debt assumed to update facilities and purchase more advanced equipment, the number of specially trained professionals on staff, and whether the hospital is located in an area suffering from a health care workforce shortage.
The mix of services that a hospital provides is directly related to overall costs and therefore charges. Special services, such as trauma, specialized heart care, and intensive care, add significantly to a hospital’s financial requirements and may attract more severely ill patients, requiring more intensive, more costly care.
Also, a number of hospitals have affiliations with medical schools to provide clinical training sites for medical students and new physicians who have completed medical school. Costs associated with operating graduate medical education programs are only partially supported by government funding, leaving the hospitals to cover the remaining costs.
Who will bill my insurer for hospital stay?
After you receive care, the hospital will bill your insurer for your care. Your insurer will send you an Explanation of Benefits (EOB) that prominently states “This is not a bill.” Bills for any amounts you owe will be sent separately by the hospital and other providers who cared for you while you were in the hospital. EOBs provide a summary of the charges submitted to the insurer for payment, the amount that the insurer paid on your behalf and any amounts that you are responsible to pay under your policy. If the insurer has negotiated discounts with the provider, the discount will be the difference between what the hospital or other provider charged and what the insurer paid plus the amount you owe the provider.
How can I take charge of my health?
The best way to avoid health care costs and expensive hospital services is to take charge of your own health. Lifestyle choices are responsible for nearly 90% of health outcomes. Our personal health is affected by the food we eat, how often we exercise, if we choose to smoke or abuse substances, and how much we sleep.
There is no shortage of credible resources and programs designed to help consumers improve and maintain the best health possible. Hospitals are excellent resources, offering a wide range of wellness programs and information.
Where can I learn more about the quality of hospital care in South Carolina?
The South Carolina Hospital Association embraces transparency of hospital quality and price. We believe that making useful information available to the public will create better informed patients with more confidence in the health care system and better prepared to make the right decisions regarding their health care.
My SC Hospital (myschospital.org) offers consumers reliable information about the quality and safety of care provided by South Carolina hospitals. Consumers can also find quality and patient safety data on Medicare's Hospital Compare website (http://www.medicare.gov/hospitalcompare).