Shopping for Shoppable Services
Sometimes you can’t shop around for healthcare. If you need emergency surgery for a heart attack, you need it right away, and can’t look for the best price. But for many health services, like cataract surgery and mammograms, you have time to plan. If you’re getting the service in a hospital or health system, you may be able to check the price ahead of time at different facilities. You can also use our Shoppable Services tool to learn the average price for the service in your area and surrounding areas. This article will explain how to use that tool.
The federal government defines shoppable services as services that a patient can schedule in advance and that are not urgent. Beginning in 2021, hospitals are required to list their prices for 300 shoppable services. Of those 300, 70 are required specifically by the government to be listed. They include such items as 45-minute psychotherapy and a CT scan of the head or brain. A hospital can choose the other 230 services from among those it commonly provides. If a hospital provides fewer than 300 shoppable services, it must list as many as it provides.
One way to shop for a shoppable service is to go to the websites of different hospitals and see what price they list. But no single format is required for the display of prices, so comparisons may not be easy. Our Shoppable Services tool offers a different approach. We have compiled a list of more than 300 common shoppable services. That list includes the 70 required by the federal government, as well as many others. We chose the services because they’re commonly performed and because many are available on the shoppable service lists at hospitals and health systems. Using our tool, you can easily browse through the services, or search for a specific service. Then you can get an estimate of what the service typically costs in the area where your provider is located.
How to Use the Tool
The tool leads you to a page in which there are several ways to find shoppable services. You can use the list of categories, from “Ambulance Transportation” to “Imaging Tests” to “Vision Supplies,” to help pinpoint the procedure code for the service you want. Or you can scroll down the menu of all types of care until you find what you’re looking for. If you already know the procedure code for the service you want, you can enter it. Or you can enter a keyword to help you find it.
Once you’ve chosen a procedure code, the tool takes you to a cost results page. The page estimates the average cost of the primary procedure and the amount of related costs, if applicable. For example, for procedure code CPT®1 45385, the primary procedure is removal of polyps or growths in large bowel using an endoscope (colonoscopy) using a mechanical snare. Related costs include a pathology procedure, in which the tissue removed is examined with a microscope, and an anesthesia procedure. The tool adds up your primary procedure and related costs to give you your total cost. You can remove related costs from your total if you don’t think they apply.
Two types of total cost are given. One is the out-of-network price. This is the average amount that FAIR Health estimates, based on our database, a provider in this area may bill for this procedure. This amount may also be called the “provider’s charge.” This is the amount you may be billed if you’re uninsured. Or if you have insurance but the provider isn’t in your network, you may be billed this amount. (If your health plan has an out-of-network benefit, the plan may pay part of this amount. That depends on the terms of your plan.)
The other type of total cost is the in-network price. This is the estimated average amount that a health plan will pay an in-network provider for this service. As members of the plan’s network, such providers have agreed to accept that amount as full payment for that service. (For more on networks, see our article on Provider Networks.)
If you’re insured and you go to an in-network provider, your costs will be determined by the cost-sharing terms of your plan. You may have to pay a deductible (a fixed dollar amount you have to pay before the insurer will start paying for services), a copay (a fixed dollar amount you pay for each service) or coinsurance (a percentage of the cost of the service). Suppose you have a deductible that you haven’t paid and the deductible is more than the cost of the service. Then the actual in-network price of the service is the amount you’ll have to pay to your in-network provider.
In addition to viewing total costs in your own area, you can also use the tool to view cost estimates for the same procedure in surrounding zip codes. That way you can see if you may be able to achieve some savings by having the procedure somewhere nearby.
How to Use Your Cost Estimate
There are several ways you can use your cost estimate. One is to plan and budget for the expense. If you know you need a certain kind of knee surgery, for example, you can use the estimate to make plans for how you’ll pay for it. This is especially important if you’re uninsured or if you have a high-deductible health plan—a plan where you have to pay a bigger deductible than a typical plan.
If you’re uninsured or going out of network, you can also use the cost estimate to negotiate with a hospital. Find out what hospitals in your area charge for the procedure. Compare their costs to the average cost estimate you got with our Shoppable Services tool. If a hospital you’re considering charges more than our cost estimate, let them know about the information you found on our site and ask if they’d be willing to accept a lower price. For more on negotiating with providers, see Using FAIR Health Cost Estimates to Negotiate the Costs of Care.
1 CPT © 2020 American Medical Association (AMA). All rights reserved.