Navigating Healthcare: Price Transparency Tools
Authored by: Mark Stamper, Vice President of Commercial Products
Understand what it all means and how to use the information to make informed care decisions.
At the beginning of 2023, a federal mandate required all commercial health plans to make 500 medical service prices transparent to consumers. Part of this law requires the plan to allow you to search network providers and receive estimates on what your out-of-pocket expense for a medical service would be.
The intent of this law is to enable you, a consumer, to make up-front decisions fully understanding the financial impact it may have on you either out-of-pocket or from your Health Savings Account (HSA). The best way to do that is by making sure you know how to get the most accurate estimates possible when using the tools.
How Transparency Tools Work
There are a multitude of solutions that your health plan may choose to offer you but the basics on how to use them are the same: choose a service, choose a provider (or vice versa), return a price. However, because they were mandated by the federal government, it means many of the current limitations are also the same. Having an understanding of how they’re built will make it easier for you to successfully navigate them.
At the core of every tool today is the list of 500 shoppable services. These 500 services are all based on individual CPT® codes* that providers perform and bill and are represented by 5 digits. These individual codes can make the search process confusing because there may be numerous codes for similar services, and you may not know which one a particular provider will perform. If you search on the wrong code, you may not get a cost estimate back, or you may be getting an estimate for a service you are unlikely to be billed for.
For example, you can shop for a 10-minute visit but that doesn’t mean you will be billed for a 10-minute visit. There is clinical discretion on the amount of time needed to adequately review your history, any questions you may have, and documentation of the required amount of information for the visit…you can shop for whatever you want, but you don’t get to choose what you’re billed for.
To help guide you through the process, here are some tips to avoid mismatches and get the estimates you’re looking for.
Search Tip 1: Modalities and Complete Care Estimates
It’s helpful to start by discussing modalities (methods of treatment or services). Almost every type of interaction with healthcare could result in a variety of other services being provided beyond the one you shop for. Even a “simple” office visit: are you due for vaccinations/shots? Which ones?
Sometimes you can choose the exact care you receive and other times, like with anesthesia, your “choice” is limited. Every situation is somewhat unique. A “one-size-fits-all” approach may not fit your exact health situation or decisions that you or your provider will make at the time of service.
The best thing you can do is try to have as full an understanding as possible of the care you are likely to receive, search for each service code, and add the costs up to get a more complete estimate.
Search Tip 2: Primary Care and Specialists
Primary Care Physician is not an official specialty so when using a tool, search for internal medicine or family medicine.
If you are searching for an office visit with a primary care physician or a specialist, and this will be the first visit you’ve had with this provider, start your search with 99203 or 99204. If you are an established patient, meaning you have seen this provider before, use99213 or 99214.
As previously mentioned, there are various ranges of time for office visits that you can get pricing for. We recommend sticking with 99204 or 99214 if you want to estimate on the high-end with a high-level of certainty that you will be billed for that amount or less.
Search Tip 3: Physical Medicine (Physical Therapy, Occupational Therapy, Chiropractic…)
Most visits in the physical medicine space will involve multiple modalities (different services). For example, the first visit might involve an evaluation (modality #1), hot or cold packs (modality #2), and one or more therapeutic exercises (modality #3 & #4). Subsequent visits will have modalities 2-4 and then towards the end of your treatment another evaluation will be done.
For a full picture of the cost of the care you may receive, you’ll have to look up codes for each individual modality. Most of these can be found in 97010 – 97813 codes for occupational and physical therapy. Chiropractic will use some of the codes in that range, but they also have specific procedures for chiropractic manipulation (98940-98943).
Search Tip 4: What You Probably Shouldn’t Shop For
Ok, this is going to be the most confusing portion of whatever tool you have available to use. First, not all the shoppable services are really “shoppable.” I’m not sure why anyone would shop for a blood draw seeing as the blood draw comes with any blood-based lab you may need.
Next, there’s emergency room visits on the list. This is questionable on many levels. If you need an emergency room visit…go! Do not shop, don’t pass Go, don’t hesitate. Going to an emergency room is a perfect example of how you can’t always shop up-front for cost. Most people have no idea what is going to happen when you get there. There may be lab tests, X-rays, heart monitors, drugs administered, plus the fees for professionals working your case.
The last one I’ll mention are normal annual labs, maybe even all labs. First, annual wellness visits are mandated to be covered in full by health plans. If you do need labs outside of that, there is a good chance your health plan has negotiated with either Quest Diagnostics, Labcorp, or some other competitive lab. Those prices are likely as reasonable as they can be, so you are unlikely to find a cheaper option with reliable results.
Applying Your Estimates
When you finish using your tool for shopping, make sure to email, text, or save the results somewhere and bring them to your appointment. Use the information you gathered to have a discussion with the medical staff, even something as simple as showing the receptionist or billing person in the office your estimate and asking, “Is this reasonable?”
If your tool is available on a mobile device, you can also check prices on services your provider is recommending you have beyond what you priced before the appointment. Remember, you are a consumer and a patient. You have a right to ask questions just like you would when purchasing any other service.
Cost is Only One Part of Your Decision
Federal mandates begin to lift the covers on the widely variable opaque cost structure that exists in our country. It’s a start---- and a start is much better than sitting still when it comes to informing the public. Just remember, these estimates are just that, estimates. Your particular needs can’t be foreseen by a simple tool covering 500 shoppable services. You and your medical professionals will have choices based on your unique circumstances. Those choices can’t always be made until all the information is available.
Let the tools be a guide to compare and contrast the starting point of what you may expect to pay. But cost is only one piece of your decision-making process. Convenience, speed to visit, quality, location, provider reviews, and a host of other factors can alter your path. The good news is that you now have some insight to cost, and that is a huge step forward.
Mark Stamper is the Vice President of Commercial Products at Opyn Market®. Having spent 20+ years in the healthcare industry, he is passionate about empowering consumers to take charge and feel good about their healthcare decisions, for the first time.
You can reach him at firstname.lastname@example.org.
*CPT® codes are a registered trademark of the American Medical Association that governs their use and upkeep.