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Charge (List Price): The amount a hospital sets for services provided to the patient before any insurance discounts. Similar to a “sticker price,” it is usually not the final amount paid.

Chargemaster (aka Charge Description Master (CDM)): comprehensive listing of items billable to a hospital patient or patient’s health insurance provider. (see also: Items and Services)

Commercial Insurance: Non-Medicare or Medicaid Insurance. Can be purchased individually, but is often obtained through your employer. Rates are negotiated between the insurance company and the hospital. These rates can differ among companies, where larger insurers tend to demand bigger discounts. The demands for discounts by commercial insurance companies create further complexity for hospitals and patients to determine the true cost of any given procedure. Commercial insurers do not pay full hospital charges. Furthermore, numerous factors, such as the type of plan, co-pay amount, co-insurance amount, deductible, out-of-pocket maximums and other limitations will affect the individual’s financial responsibility to a hospital. Therefore, it is crucial that you begin by talking to your insurance company to understand all of the factors affecting your financial responsibility.

Commercial Reimbursement (Payment): The amount a commercial insurer pays to the hospital for inpatient stay or outpatient services from commercial insurance provider. Rates are negotiated between the insurance company and the hospital.

Contractual Adjustment: The adjustment made by the hospital after both insurance and patient out of pocket is communicated from the insurance.

Cost: Amount that represents what the hospital actually spends or pays to acquire or purchase source materials or provide services (i.e. devices, supplies, drugs, diagnostic and therapeutic services, etc.)

Government Reimbursement (Payment): The amount/rates determined by state and federal governments that Medicaid/Medicare would pay hospitals for a given service.

Hospital Standard Charges: CMS finalized the definition of ‘standard charges’ to include the following:

  • Gross Charge (see also: Charge (Price)): The charge for an individual item or service that is reflected on a hospital’s chargemaster, absent any discounts.
  • Discounted Cash Price: The charge that applies to an individual who pays cash, or cash equivalent, for a hospital item or service.
    • This price is the discounted cash rate unrelated to any charity care or bill forgiveness reductions.
  • Payer-Specific Negotiated Charge: The charge that a hospital has negotiated with a third-party payer for an item or service. Medicare and Medicaid fee-for-service rates are not considered to be payer-specific negotiated rates because they are not subject to negotiation. However, Medicaid managed care and Medicare Advantage rates are within the scope of this definition.
  • De-Identified Maximum and Minimum Negotiated Charges: The lowest and highest charge that a hospital has negotiated with all third-party payers.

Items and Services*: Per CMS, defined to mean all items and services (including individual items and services and service packages) that could be provided by a hospital to a patient in connection with an inpatient admission (DRG) or an outpatient department visit for which the hospital has established a standard charge.

Examples include, but are not limited to, the following:

  • Supplies and procedures
  • Room and board
  • Use of the facility and other items (generally described as facility fees)
  • Services of employed physicians and non-physician practitioners (generally reflected as professional charges)
  • Any other items or services for which a hospital has established a standard charge

*Depending on your insurance plan and or service provided, an authorization may be required in order for services to be approved/eligible for payment.

Medicare: Health insurance program for individuals 65 or older, or individuals under the age of 65 with certain disabilities or conditions. For Medicare, hospitals generally receive payment of only $0.86 cents for every dollar of actual cost of providing care. (Source: American Hospital Association)

Medicaid: A joint Federal and State program that helps with medical costs for people with low incomes. For Medicaid, hospitals generally receive payment of only $0.89 cents for every dollar of actual cost of providing care. (Source: American Hospital Association)

Out-of-Pocket costs (Payment): The amount a patient pays to the hospital after reimbursement from patients’ insurance provider (for example, deductible or co-pay).

  • Co-Pay: A fixed rate that an insured policyholder will pay for a specific type of service.
  • Co-Insurance: The percentage of costs of a covered health care service you pay after you met your deductible.
  • Deductible: A specified amount of money that an insured policyholder must pay before an insurance provider will pay any expenses.
  • Out-of-Pocket Maximum: The maximum you have to pay for covered services in a plan year. After you spend this amount (including deductibles, co-payments, and co-insurance), your health plan pays 100% of the costs of covered benefits.

Price Estimator Tool: An interactive tool that combines data from the provider’s chargemaster, claims history, payer contract terms and the patient’s insurance benefits to allow healthcare consumers the ability to obtain an estimate of the amount they will be obligated to pay the hospital for the selected shoppable service. Access SWG’s tool here: Patient Bill Estimator.

Self-Pay: When a patient pays for a health-related service when they do not have insurance to cover their medical treatment or surgery. For patients who do not have insurance, or who have limited insurance coverage, hospitals typically have financial assistance programs for those that qualify. Please contact the Financial Clearance department to determine if you qualify for any programs they may offer.

Shoppable Services: A set of the most commonly performed services provided by the hospital that are often scheduled in advance (e.g., imaging, labs, colonoscopy, cesarean delivery and related care).

Sample Charge Breakdown Scenario:

Below is an example of how the above terms are applied, the dollar amounts are for illustrative purposes only and are not meant to reflect actual pricing/contract rates.

Knee Replacement Total Charge (List Price): $38,000

Contractual adjustment: The insurance company has negotiated a 30% discount with the hospital. This equates to an $11,400 discount off the list price.

Patient Out-of-Pocket costs: The patient’s insurance plan has a $1,000 deductible. This is the amount that patient would be responsible to pay out of pocket for this service.

Allowed Amount (Hospital Reimbursement): This is the total amount to be paid (between insurance and patient) for this service. (List Price - Contractual Adjustment) = $26,600. Therefore, the hospital will receive $1,000 from the patient and $ 25,600 from the insurance.