Public Viewing of Hospital Charges
Requests to View Hospital Standard Charges:Pinckneyville Community Hospital has historically publicly displayed in its Registration Department the hospital charges for its most common procedures. A new federal rule, effective 10/1/14, entitled Requirement for Transparency of Hospital Charges Rule in the Affordable Care Act, requires hospitals to make public their standard charges for items and services provided by the hospital. This rule allows hospitals to either make public a list of their charges (their charge master or another form of their choice) or their policy for allowing the public to view a list of those charges. Pinckneyville Community Hospital has elected the latter option. This handout explains the procedures for public viewing of hospital charges.
The Requirement for Transparency of Hospital Charges Rule is intended to assist patients in understanding their potential financial liability for services obtained at our hospital and to allow comparison for similar services across hospitals. However, hospital charge masters are lengthy and complex documents which do not provide information at a level that is easy to understand for this purpose. Therefore, additional information, as outlined below, is available to patients seeking price estimates so as to help aid better understanding of hospital charges.
HFMA's Understanding Healthcare Prices: A Consumer Guide:The nationally based Healthcare Financial Management Association (HFMA) developed the HFMA's Understanding Healthcare Prices: "A Consumer Guide" to aid patient understanding of hospital charges. A copy of this guide is provided on the Hospital's website at www.pvillehosp.org.
Definitions:Hospital charges are the amounts set before any discounts. Hospitals are required by the federal government to utilize uniform charges as the starting point for all bills. Charges are based on what type of care was provided and can differ from patient to patient for the same service depending on any complications or different treatment provided due to the patient's health. Therefore, actual charges for a specific patient will differ from the listed standard charges.
These charges represent the standard charges for procedures and diagnosis-related groups. The charge is for care without complications. Actual charges may be different for specific patients due to medical condition, length of time spent in surgery or recovery, necessary specific equipment, supplies or medication, complications requiring unanticipated procedures or other treatment ordered by the physician.
Discounts & Financial Assistance:Many patients seeking hospital charge information are interested in knowing what their out-of-pocket financial responsibility will be. This is an opportunity to have important conversations regarding payment options, including prompt payment discounts for paying patient balances in full within 30 days of initial statement indicating the balance due from the patient.
If a patient has health insurance, significant discounts have already been obtained by the insurance company and the patient only needs to pay the deductible, copay and/or coinsurance. Patients should contact their health plan directly for their specific financial obligations that aren't reimbursed by insurance.
Pinckneyville Community Hospital has a financial need assistance program whereby uninsured and insured patients may qualify for discounted services based on household income as compared to the Federal Poverty Level. Those without health insurance may also qualify for discounts under the Illinois Hospital Uninsured Patient Discount Act and any other discounts. Please visit the Patient Financial Assistance section of the hospital website at www.pville.org or inquire about the financial need assistance program and Illinois Hospital Uninsured Patient Discounts with the Hospital's Patient Financial Counselor for further assistance.
Price Estimates:Requests for price estimates should be directed to the Hospital's Patient Financial Counselor.
Price estimates are not a quote or a guarantee of what the charges will be for a specific patient's care. This charge information generally does not include the professional services provided by a physician, surgeon, radiologist, anesthesiologist/certified registered nurse anesthetist, pathologist, advanced practice nurse, physician assistant or other independent practitioners.
Patients will receive separate bills for the independent 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.
Public Viewing of Hospital Standard Charges:Hospital charge masters are lengthy and complex documents and do not provide information at a level conducive for promoting transparency for patients to understand their potential financial liability for services obtained at our hospital and to allow comparison for similar services across hospitals. Requesting a pricing estimate for specific services a patient is seeking to have performed at the hospital is the recommended choice for patients to gain a better understanding of their financial responsibility. However, requests by patients for the Hospital's charge master detail list should be made through the Hospital's Chief Financial Officer.
Quality Care:An important component for choosing a health care provider is determining quality of care. Your doctor can be a helpful resource in choosing where to obtain care. Further Medicare hospital-specific quality outcome measures are located on the Hospital Compare website at www.medicare.gov/hospitalcompare.
To compare hospital median charges for nearly 50 major diagnoses, quality and patient satisfaction metrics in Illinois, go to the Illinois Hospital Report Card website at www.healthcarereportcard.illinois.gov.
Frequently Asked Questions:
1. How much will I actually have to pay out of my pocket?For insured patients, health plans such as Medicare, Medicaid, workers' compensation, commercial health insurance, etc., do not pay charges. Instead, they pay a set price that has been predetermined or negotiated in advance. The patient only pays the out-of-pocket amounts set by the health plan. Therefore, a patient with health insurance needs to pay the deductible, copay and/or coinsurance set by their health plan.
The financial obligations could differ depending on whether the hospital or physicians are "out-of-network," meaning the health plan does not have a contract with them. Contact your insurance company to understand what your financial obligations will be.
If you need help understanding your health care bill, please contact the Hospital's Billing Department.
A patient without health insurance will be able to discuss financial assistance options available that could include either a complete write-off or a substantial reduction of the charges in accordance with the Illinois Hospital Uninsured Patient Discount Act and the hospital's financial assistance program.
Please visit the Patient Financial Assistance section f the hospital website at www.pvillehosp.org or inquire about the financial need assistance program and Illinois Hospital Uninsured Patient Discounts with the Hospital's Patient Financial Counselor for further assistance.
2. What do the following health insurance terms mean?Deductible means the amount the patient needs to pay for health care services before the health plan begins to pay. The deductible may not apply to all services.
Copay means a fixed amount (for example, $20) the patient pays for a covered health care service, such as a physician office visit or prescription.
Coinsurance means the percentage the patient pays for a covered health service (for example, 20% of the bill). This is based on the allowed amount for the service. You pay coinsurance plus any deductibles you owe.
A patient's specific health care plan coverage, including the deductible, copay and coinsurance, varies depending on what plan the patient has. Health plans also have differing networks of hospitals, physicians and other providers that the plan has contracted with. Patients need to contact their health plan for this specific information.
3. What is the difference between charges, cost and price?Total Charge is the amount set before any discounts. Hospitals are required by the federal government to utilize uniform charges as the starting point for all bills.
The charges are based on what type of care was provided and can differ from patient to patient for similar services, depending on any complications or treatments provided due to the patient's health.
Cost - For a hospital, it is the total expense incurred to provide the health care. Hospitals have higher costs to provide care than freestanding or retail providers, even for the same type of service. Hospitals are open 24 hours a day, 7 days a week and are prepared to provide care in emergencies. Non-hospital health care providers can choose when to be available and typically would not provide services that would result in losses.
A hospital's cost of services can vary depending on additional factors such as:
Types of services it provides at a loss such as emergency room;
Providing community screenings and education programs;
Number of patients with significant illnesses and payment doesn't cover treatment costs;
Patients who are on public assistance which pays less than the cost of care provided
Uninsured patients who are unable to pay much if anything toward the cost of their care.
Total Price is the amount actually paid to a hospital. Hospitals are paid by health plans and/or patients, but the total amount paid is significantly less than the starting charges.
Medicare pays hospitals much less than the hospital charge and typically less than their total costs.
Medicaid reimbursement is even lower and significantly below actual cost.
Commercial insurers negotiate discounts with hospitals on behalf of their enrollees and pay hospitals at varying discount levels, but much less than starting charges.
Patients may also qualify for discounted services based on household income as compared to the Federal Poverty Level. Please visit the Patient Financial Assitance section of the hospital website at www.pvillehosp.org or inquire about the financial need assistance program and Illinois Hospital Uninsured Patient Discounts with the Hospital's Patient Financial Counselor for further assistance.
4. How can I use this hospital charge information for comparing prices?Charge information is not necessarily useful for consumers who are "comparison shopping" between hospitals because the descriptions for a particular service could vary from hospital to hospital and what is included in that description. It is difficult to try to independently compare the charges for a procedure at one facility versus another. An actual procedure is comprised of numerous components from several different departments - room and board, laboratory, other diagnostics, pharmaceuticals, therapies, etc.
A patient who has the specific insurance codes for services requested, available from their physician, can better gauge charge estimates across hospitals. Ask your physician to provide the technical name of the procedure that has been recommended as well as the specific ICD and CPT codes for service.
5. How can I get an estimate for a specific procedure?If you need an estimate for a specific procedure or operation, please contact the Hospital's Patient Financial Counselor.
Such estimate will be an average charge for the procedure without complications. A physician or physicians make the determination regarding specific care needed based on considerations using the patient's diagnosis, general health condition and many other factors. For example, one individual may require only a one-day hospital stay for a particular procedure, while another may require a two-day stay for the exact same procedure.
Remember that the patient will not pay charges. Rather, the patient with health insurance will only pay the specified deductible, copay and coinsurance amounts established by their health plan. A patient without health insurance or sufficient financial resources may be eligible for significant discounts from charges. Please contact the Hospital's Patient Financial Counselor for further information.
Patient Financial Counselor: 618-357-5906
Hospital Billing Department:
Medicare Billing: 618-357-5919
Commercial Insurance: 618-357-5921 or 5973