No Surprise Act Disclosures
At Pinckneyville Community Hospital, we agree that transparency about the cost of health care is important. Listed below are several resources to help patients understand and compare costs.
As you review this information, here are a few considerations to keep in mind:
- These charges are rarely the price that patients pay. The chargemaster lists the dollar amount set for each service prior to insurance contract/benefit plan discounts or financial assistance discounts being applied, so the price patients pay tends to be less than the standard charge.
- Hospital charges differ from patient to patient for the same service depending upon variations in treatment.
- Items included in a charge vary across hospital systems. For example, what's included in one hospital's charge for room and board may differ from another hospital's charge. Some hospitals bundle services together into a single charge that others may list separately.
- Looking at various hospital charges does not provide any indication of quality of service and outcomes.
- Independent practitioners providing services at Pinckneyville Community Hospital, including but not limited to, some surgeons, radiologists, pathologists, and specialty clinic practitioners, bill for their services separately and are responsible for their own insurance plan participation agreements. Independent practitioners MAY NOT be participating providers in the same networks as the hospital. If you will be receiving services from an independent practitioner, we strongly encourage you to contact your insurance plan for participating provider information. New practitioners to the Family Medical Center may also not be considered participating practitioners until they are approved by each individual insurer's credentialing department.
Resources for Understanding Healthcare Pricing
Helping Patients Better Understand Hospital Charges & Out of Pocket Responsibility
The nationally based Healthcare Financial Management Association (HFMA) developed an aid to assist patients with better understanding of hospital charges. A copy of this guide is herein provided: HFMA Understanding Healthcare Prices, A Consumer Guide.
Illinois hospitals are committed to and working on improving price transparency that will provide the most meaningful and useful information for patients and consumers. It is important to note:
- Federal law requires hospitals set uniform charges (the amount set before any discount) as the starting point for all bills.
- The starting list of charges is the same for every patient. But the charges may vary by patient even though a similar procedure was performed. This may be due to the patient's medical condition, length of time spent in surgery or recovery, complications requiring unanticipated procedures, kinds of medication needed, etc.
- Illinois hospitals are not paid these charges by patients or health plans.
What does the health plan pay?
- Commercial insurers negotiate discounts with hospitals on behalf of their enrollees and pay hospitals at varying discount levels, but much less than starting charges. Medicare and Medicaid pay according to a regulated fee schedule - both pay at much less than what it costs the hospital to provide the service.
- Medicare and Medicaid pay hospitals based on pre-set rates that can vary among individual hospitals because they may reflect the variation in a hospital's cost to provide that care, such as trauma, teaching programs, severity of illness and area wages among other things.
- On average, Medicare pays Illinois hospitals only about 90% of what it costs hospitals to provide the care and Medicaid payment is much less.
How much will a patient pay?
- Although all bills start with charges, patients without health coverage are protected by Illinois' groundbreaking legislation, the Hospital Uninsured Patient Discount Act. It causes bills to eligible uninsured patients be either completely written off (free) or have significant discounts applied (bill reduced to 135% of the hospital's cost). In addition, there is a maximum collectible of 25% of annual family income. Please see additional information on the Pinckneyville Community Hospital website for details about applying for this patient financial assistance or contact our Patient Financial Counselor at 618-357-5906.
- Patients with health coverage will only pay the deductible, coinsurance or copay required by their health plan. Although hospitals can assist with estimated charge information for the service being sought, the health plan is the best source of information pertaining to what an insured patient will pay.
Important Contact Numbers for Pinckneyville Community Hospital Billing and Financial Assistance
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.
Hospital Price Transparency: Patient Frequently Asked Questions (FAQs)
- 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.
- A patient without health insurance will 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 see additional information on the Pinckneyville Community Hospital website for details about applying for patient financial assistance or contact our Patient Financial Counselor at 618-357-5906.
Health Insurance Plan pays:
- 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.
- Deductible means the amount the patient needs to pay for healthcare services before the health plan begins to pay. The deductible may not apply to all services.
- Copay means a fixed amount (e.g., $20) the patient pays for a covered healthcare service, such as a physician office visit or prescription.
- Coinsurance means the percentage the patient pays for a covered health service (e.g., 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 healthcare 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.
- 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 different treatment provided due to the patient's health.
- Cost: For a hospital, it is the total expense incurred to provide healthcare. Hospitals have higher costs to provide care than freestanding or retail providers, even for the same type of service. This is because a hospital is open 24 hours a day, 7 days a week and needs to have everything necessary available to cover any and all emergencies. Non-hospital healthcare 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 since many vital services are provided at a loss;
- Providing medical education programs to train physicians, nurses and other healthcare professionals, again provided at a loss;
- More patients with significantly higher levels of illness, yet payment doesn't cover;
- A disproportionately high number of patients who are on public assistance or uninsured and 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.
- On average in 2017 Medicare paid Illinois hospitals only 90% of a hospital's cost to provide that care and Medicaid pays even less.
- Medicare and Medicaid pay hospitals according to a set fee schedule depending on the service provided, much less than the hospital's total charge and actually less than their costs.
- Commercial insurers negotiate discounts with hospitals on behalf of their enrollees and pay hospitals at varying discount levels, but much less than starting charges.
- 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.