Understanding Your Insurance Coverage
Helpful Documents
Q: What is the difference between charges and costs?

A: The amount a facility bills for a patient's care is known as the charge. This is not the same as the actual cost or amount paid for the care. The amount collected by a health care facility for each service is almost always less than the amount billed. There are three common examples:

  • Government programs such as Medicare and Medicaid typically pay health care providers much less than the billed charge. These payments are determined by government agencies. Hospitals have no ability to negotiate reimbursement rates for government-paid services.
  • Commercial insurers or other purchasers of health care services usually negotiate discounts with health care facilities on behalf of the patients they represent.
  • Hospitals typically have policies that allow low-income persons to receive reduced-charge or free care.

Negotiations between hospitals and payers generally begin with the charge amount. While each facility's charge structure may vary in important ways, charges represent a consistent, though imperfect, way to compare health care costs.

Q: Why are charges for the same procedure higher at one hospital than another?

A: Charges Vs. Costs

The amount a facility bills for a patient's care is known as the charge. This is not the same as the actual cost or amount paid for the care. The amount collected by a health care facility for each service is almost always less than the amount billed. There are three common examples:

  • Government programs such as Medicare and Medicaid typically pay health care providers much less than the billed charge. These payments are determined by government agencies. Hospitals have no ability to negotiate reimbursement rates for government-paid services.
  • Commercial insurers or other purchasers of health care services usually negotiate discounts with health care facilities on behalf of the patients they represent.
  • Hospitals typically have policies that allow low-income persons to receive reduced-charge or free care.

Negotiations between hospitals and payers generally begin with the charge amount. While each facility's charge structure may vary in important ways, charges represent a consistent, though imperfect, way to compare health care costs.

Q: What is the best way to understand my bill?

A: Health care billing can be very complex, but there are some ways to check your bills so that you understand what you, your insurance and/or your employer is paying for:

  1. Make sure you have received all services listed, and understand why.
     
  2. Check dosages and amounts for accuracy.
     
  3. Note the total cost of care, and how much your insurance or employer has paid.
     
  4. If you do not understand any part of your bill, ask your health care provider to explain it.
     
  5. This charge information does not include the professional services provided by a physician, surgeon, radiologist, anesthesiologist, pathologist, advanced practice nurse or other independent practitioners.
     
  6. This information is not a quote or a guarantee of what the charges will be for a specific patient’s care.
     
  7. Patients will likely receive separate bills for the physicians and other professionals who provided treatment. These physicians may not be participating providers in the same insurance plans and networks as the hospital. As such, there may be greater patient financial responsibility for these services which are not under contract with the health plan.
Q: How can I save money on my health care?
  1. Don’t use a Specialist or Emergency Room for basic health care.
     
  2. Only use the Emergency Room for true emergencies.
     
  3. Use generic drugs whenever possible; ask your doctor to prescribe a generic first!
     
  4. Seek comparable care in lower cost settings.
Q: How can I avoid surprise billing

A: Read this guide from AHA on Avoiding Surprise Bills.

Q: What questions should I ask when choosing a new provider?

A: The following questions should help when selecting your new provider.

Q: Is this hospital in-network or out-of-network?

A: Prices can vary widely depending on whether your hospital is in- or out-of-network for your specific health plan. Out-of-network hospitals have not been able to negotiate a discounted price with your insurer, thus making you potentially responsible for higher personal payments.

Q: Is the hospital physician providing care in-network or out-of-network?

A: 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 for surgery or pregnancy delivery along with 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.

Q: Is it possible my bill will be higher than expected?

A: Yes, services and procedures may be different based on age and level of health (for example, uncontrolled diabetes and high blood pressure).