Care Beyond the Physician's Office

Our applications include providers with practice addresses in the following states. Additional states are under development.

Shopping Techniques

The government has created an opening for you to become a consumer of healthcare services vs. a passive recipient. Several key 'protections' have been introduced for this journey. The protections are dependent on you knowing the details. For example, out of network protection could be negated by you signing a form. Follow the link below to learn more.

Consolidated Appropriations Act of 2021

"The Consolidated Appropriations Act of 2021 established several new requirements for providers, facilities, and providers of air ambulance services to protect consumers from surprise medical bills. These requirements are collectively referred to as “No Surprises” rules. Among other things, these include prohibiting balance billing in certain circumstances and requiring disclosure about balance billing protections, requiring transparency around health care costs, providing consumer protections related to continuity of care, and establishing requirements related to provider directories.
These requirements generally apply to items and services provided to consumers enrolled in group health plans, group or individual health insurance coverage, and Federal Employees Health Benefits plans. The requirements for transparency of health care costs and the requirements related to the patient-provider dispute resolution process also apply to uninsured consumers." (CMS.gov)

Comparing Providers: Find & compare providers near you via CMS.

A government provided resource for comparing all types of providers is Medicare.gov. It allows you to search for most types of clinical services and where available provides quality scores and patient satisfaction scores. Use the link below:

Background: Pricing Methods

This section is derived from our experience gathering and preparing for comparing posted hospital prices.

Almost all hospitals price services on what other industries would term T&M or 'time & materials'. One good reason for this approach is the variability encountered when treating a human being. Variation occurs in two main categories:
           1. Personal characteristics: age, concurrent health issues, .....
           2. Condition characteristics: amount of work/time involved in resolving/treating, additional resources required to resolve, .....
Some services are reasonably predictable while the extent of others are not known until they are undertaken.

Examples:
           Easier: Cat Scan w/contrast of a 30 year old vs. 70 year old. The 70 year old will generally require an additional lab test to determine the kidney's ability to clear the contrast when the 30 year old will generally not require the lab unless some other condition requires it.
           Harder: Colonoscopy and the type or number of interventions are determined (time,..) during the procedure (visual inspection, biopsy,..)

Some interventions (treatments) are dependent on
           1. your ability or willingness to adapt new behaviors or actions, for example in physical therapy
           2. if a doctor performed procedure, the doctor's technique(s)/protocol

Price comparison techniques

1. When you receive a doctor's order,
   be sure to know the related procedure code(s). The office staff should know them as many times they have to submit them to the insurance company for approval.
2. For services with non-defined limits
   such as therapy, invasive procedures, surgeries, etc.,
        - Start by comparing base unit prices
             * Therapies & Procedure Rooms price in time segments (ex. therapy - 15 minutes; procedures - 30 minutes)
        - Ask what are the typical AND the high prices (i.e.range).
3. Start by comparing the CASH price
   to find lower cost providers as cash prices generally reflect a provider's list prices. It is the most comparable figure given how providers generate posted insurer prices.
        - then select and compare an insurer
        - use the link to the provider's cost estimator tool
        - call the financial counselor's contact number and follow the procedures below.
4. ALWAYS OBTAIN A GOOD FAITH ESTIMATE
   Use cost estimator link but for more involved services call the financial advisor phone number.
   Read the next steps prior to calling!
5. Ask what related services are usually conducted
   and if they are included with the procedure code(s) pricing. For example,
        - therapy typically starts with an assessment (a separate code) then a treatment plan (types/duration) is developed (more codes)
        - interventions typically require pre-assessments (labs, anesthesiology, medical clearances, ...) or post-treatment such as rehab
6. Special questions for therapeutic services:
        - Are various methods of therapy used, do their prices vary and at what point are they employed?
            * For example, a session with a therapist vs. an assistant vs.in a group vs self directed.
        - What is the typical frequency for sessions (ex. 2x week) and for how long?
        - What is the typical duration of treatment (ex. 10 weeks).
7. Ask if any discounts are available
   ‍especially if you are having multiple services. For example,
        - the above mentioned intervention pre-assessment
        - some providers will have reduced pricing if bilateral (both sides) are studied (ex. Bilateral Knee MRI)
        - if multiple services are commonly ordered together (ex. MRI & Physical Therapy)
        - some interventions require follow-up treatment (ex. Cardiac Rehab)
   You always have the option to have related services performed elsewhere less expensively. In fact, for pre-intervention assessments, it is more work for the provider if your assessment is done elsewhere.
8. Most of the time you will be speaking to a financial counselor or a scheduler.
   They typically are not prepared to discuss clinical processes and if they do, they use the experience gathered indirectly via their experience in the non-clinical position. You may need to speak with the service department to obtain critical information enabling you to learn what to expect.
   Remember most providers and their staff are not familiar with a consumer oriented environment. They typically focus on developing doctor referrals. Most should be helpful however.

Understanding the Data

In this section, we will explain the source(s) of price data within the application and the implications of using this data to find more affordable prices. At the end of this section, we summarize the number of hospitals in our database by state.

We intend to solicit other clinical providers, not covered by the price transparency rules, with similar services to also participate.

Hospitals tend to post their annual prices between October and January. We will be updating our data files during this time period. The price data in our current database was collected between March - May 2023 from price transparency files hospitals posted on their website. We collected similar data during 2022 and used it as a learning experience.  Hospitals are generally posting their CDM or Charge Description Master with 'prices' by insurance company/plan. Some implications to understand include:

• ONLY ITEMS WITH PRICES EQUAL OR GREATER THAN $20.00
  are included for space considerations
• ONLY SERVICES/ITEMS WITH CODES ARE INCLUDED.
  In order to compare providers, we can only use standard code sets thus any service/item without a CPT, HCPCS or DRG will not be retrievable.
• ONLY OFFICIAL CODES ARE RETRIEVABLE.
  Some providers modified official codes with their own 'technique' making them uncomparable and thus non-retrievable. A simple example is where a procedure code was expanded with an addition such as LT or RT (left or right). Most times there is no price difference. We assume there was some internal reasoning. However, the code is not comparable across providers. Several providers did separate modifiers and their codes are not impacted.
  
• SOME SERVICES MAY NOT HAVE A PRICE FOR AN INSURER (but don't stop there).
  Many files did not list prices for all their services for each insurer. This may indicate the missing prices were not performed with that particular insurer. This doesn't mean that provider does not have a price and the service couldn't be performed with that insurer.
  
• ALL SERVICES DO TEND TO HAVE A CASH PRICE.
  With the exception of inpatient services (DRG), most providers did list a cash price for each service in their CDM. This is why we recommend including SELF PAY/CASH in your search.
• PROVIDERS DEFINED INSURERS DIFFERENTLY.
  Most providers 'grouped' plans into a general description. For example, commercial plans vs. medicare plans. However, some providers further defined that grouping into smaller groups such as commercial using a more specific name (ex. Aetna Plans w/specific names).
  We also had to 'interpret' the naming process and attempted to 'match' them to other providers listings.
  This is why we recommend using the provider's Cost Estimator tool (link provided) and obtaining Good Faith estimates as your final step. Use the apps as a way of finding potential providers quickly.
• ALL POTENTIAL LOCATIONS MAY NOT BE INCLUDED.
  The provider address is their 'main' location via their website. The provider may have other service locations but until they provide us with the service codes related to those locations those addresses are not included. We can not assume all services are offered at all their locations.
• PHARMACEUTICALS ARE NOT INCLUDED.
  As most consumers are not going to a hospital for medications and the volumes are hugh, we did not include drugs in the applications. However, we did provide access to pharmacy comparison apps on a separate page.
• SOME CODES HAVE MULTIPLE PRICES.
  Two frequent and one rare reasons for a specific code to have multiple prices include:
       1. Some codes are inclusive of a range of options either in size, duration, quantity, etc. These tend not to be codes a consumer would search.
       2. Some codes are 'modified' by the provider to include prices for varying levels of work or resources. These codes could be common          searches by a consumer.
       3. Some providers could have two insurers (i.e. plans) when another provider has one insurer that is equivalent. This is rare. In the DeepDive          app you can drill down to plans details.
  We decided to post the most expensive 'option' since a code 'should be' the same across providers. However, we also included the lower prices via a link. This may in some cases indicate to you that the lower prices may fit your situation and it would be worth the effort to contact that provider. We tend to see multiple pricing occur in the lower priced providers.

Employer - Employee Driven Shopping Techniques

Employers, small or large, can employ several techniques to assist their employees access healthcare providers that they can afford.

• Ensure the lower cost providers, within travel distance, are included in your network.
        - Use the DeepDive application to sample common services your employees use across providers within a travel distance.
        - Use the Self Pay rate in the step above as it usually represents a % of the provider's list price (many providers use the same % discount)
        - You might also compare the Self Pay rate(s) to what you have paid in the past
• Call even if not in your network.
  Providers who want to capture your business will call your insurer,  and negotiate a price for the service(s) your employee needs. Enough business will 'stimulate' the provider and insurer to go to a more formal relationship.
• Consider offering mileage reimbursement for employees using lower cost providers beyond a set travel range (ex. 25 miles).
• Ensure employees have access to the QuickConnect and DeepDive applications to price shop.
• Develop a 'preferred provider' relationship with a lower cost provider (see description below). This a common practice in healthcare. We can provide example prices in your state/area if you contact us.
• If you are a small group employer, consider working through an employer group, such as a Chamber of Commerce, to develop a 'preferred provider' relationship.
• Third Party administrators (TPA) are a common, easier, route. Be sure to understand your ability to select providers initially and throughout the contract period. You might also obtain prices for common services the TPA obtains prior to engaging them and compare them using our applications. If you need assistance finding price comparisons, let use know.

Approaching a Healthcare Provider for affordable services

WHAT YOU BRING TO THE TABLE:
To begin, understand that healthcare providers
     - are employers and tend to be self-insured,
     - compete for business via pricing (witness the self-pay rate variation on the home page),
     - you are a customer bringing significant business both in the short term and the long term
           * as patients tend to 'stick' with providers they come to trust
           * healthcare providers have a 'network' of services that may be needed by your employees over time
     - private payers (you) tend to contribute significant profit to healthcare providers that supplement lower payer sources (Medicare,Medicaid,...)
     - you provide a consistent source of business, as an employer, that the provider doesn't need to 'advertise' to obtain, the 'word of mouth' advertising
       your employees provide, and as you add employees you add to their business potential

HOW TO PREPARE
Gather your demographics:
     - workforce demographics: Number, Sex, Age, Family Size, Zip Code residence
     - historical medical utilization: # of employees used, Services by volume, List of doctors used by employees
     - are you using any clinical services that the prospective provider(s) do not provide
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WHAT TO NEGOTIATE 
Key aspects provider will want to consider:
     - What % of employees are willing to change doctors (to the provider's) now and/or over time (ex. a new need occurs)
           * This may be an assumed quantity. For example, anyone without a primary doctor may be assumed to be willing while employees with
             established doctor relationships may not.
     - Will the agreement require employees to use the provider (for at least new services vs. established)
     - Are other providers included as choices for your employees
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WHAT OPTIONS TO NEGOTIATE
Some options to consider:
     1. Flat discount % from list prices
     2. Obtain the provider's self insured rates for their employees
Typically, providers may want to agree to a rate relative to Medicare (ex. 200% of the medicare rate for a service). If you want to know what percentages are typical we can search files for you. If you are approaching them via a large group (i.e. chamber of commerce) you should have an more leverage.
Note: Medicare rates vary by provider based on a Medicare formula that compensates for local variations.

WHO TO CONTACT
     1. Start with the Chief Financial Officer (CFO)
     2. If a larger organization, you may be referred to a contract development resource
     3. You could also be contacted by a marketing representative or a new business representative
Generally, the CFO, if not directly involved with you, will keep you on their follow-up to do list. Don't hesitate to stay in touch with their office.
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