Price Transparency

A shoppable service is a service that can be scheduled in advance. As defined by the federal government, shoppable services are those that are routinely provided in non-urgent situations that do not require immediate action or attention to the patient, thus allowing the patient to price shop and schedule a service at a time that is convenient for them.

Additionally, the Price Transparency Final Rule states that charges for shoppable services should be displayed as a grouping of related services. This means that the charge for the shoppable service (primary service) is displayed along with charges for ancillary items and services the hospital typically provides along with the primary shoppable service. For example, the estimate may include charges frequently associated with the requested procedure such as laboratory or facility fees. This helps consumers see the cost of the service in the same way they experience the service.

While shoppable services are those that can be scheduled in advance, they are not services that are always scheduled in advance. For example, certain imaging or laboratory tests can be scheduled in advance in non-emergency situations, but would not be in an emergency situation.  A hospital may include these services in its list of shoppable services, even though they are not shoppable in all situations.

Healthcare terminology may be confusing, especially when you’re navigating insurance codes and billing information. Here are a few definitions you will see associated with the rule:

• Standard charge: This is the standard price of items and services available through the hospital. Please keep in mind that the final cost of services and care will vary based on many factors, including the time of year service was received, insurance and if any complications arise during care.
• Charge: This is the final amount billed to your insurance for an item or service.
• Chargemaster: The chargemaster is the large file that includes the list of standard charges for all services and items.

Find more answers to frequently asked billing questions.

Recognizing you may see multiples charges listed for a service, it is important you understand why and what they are. The rule specifically defines four types of standard charges the hospital is required to provide in a consumer-friendly display. These include:

• Discounted cash price: The charge applied to an individual who pays cash (or cash equivalent) for a specific item or service.
• Payer-specific negotiated charge: The charge a hospital has negotiated with a third-party payer (such as an insurance company) for a specific item or service.
• De-identified minimum negotiated charge: The lowest charge a hospital has negotiated with all third-party payers for an item or service.
• De-identified maximum negotiated charge: The highest charge that a hospital has negotiated with all third-party payers for an item or service.

In addition to the estimation tool, Phoenix Children’s has also provided a machine-readable file that includes all codes and all payer contract rates for all services. There is a machine-readable file listed below for both Phoenix Children’s as well as for the employee health plan. This is in accordance with the Hospital Price Transparency Final Rule.

View the machine-readable file.

View the machine-readable file-employee health plan.

This link leads to the machine readable files that are made available in response to the federal Transparency in Coverage Rule and includes negotiated service rates and out-of-network allowed- amounts between health plans and healthcare providers. The machine-readable files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

The Hospital Price Transparency Final Rule requires that Phoenix Children’s select shoppable services that are commonly provided to the general public. If Phoenix Children’s does not provide one or more shoppable services, we will indicate this with “N/A” or a clear statement that the service is not provided. Phoenix Children’s is not required to make public Medicare and Medicaid fee-for-service (FES) reimbursement rates because such data is publicly available.

Phoenix Children’s also has flexibility in formatting shoppable services standard charges. However, the information must be updated each year to ensure it reflects any recent changes. Phoenix Children’s will clearly indicate the last date pricing information was reviewed and updated, as required by the law.

The information provided through our shoppable services list is an estimate and is not a guarantee of the final billing charges. Your actual bill may vary from the estimate based on the patient’s medical condition, unknown circumstances or complications, final diagnosis and recommended treatment ordered by your physician, among other things. Your estimate is based on a current procedural terminology (CPT) code, which can also affect your final bill if the incorrect code is inadvertently used by you in the pricing tool or if recommended treatment changes. Rates are subject to change. You should not rely on the information provided in your estimate to determine the actual amounts owed by you and your insurance company.

Professional fees, such as physician, radiologist, anesthesiologist and pathologist may not be all-inclusive in this estimate. This is an estimate only and not a guarantee of payment. Final payment may differ.

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible.

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

Emergency services
If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Additionally, Arizona law protects patients from surprise medical bills for: (i) emergency services and health care services directly related to the emergency services provided during an inpatient admission by an out-of-network provider at an in-network facility; and (ii) non-emergency health care services provided by an out-of-network provider, at an in-network facility, if the out-of-network provider did not provide the patient/patient’s authorized representative a written disclosure prior to the health care service or the patient/patient’s representative chose not to sign the referenced disclosure. The law applies to patients with coverage through a disability insurer, group disability insurer, blanket disability insurer, hospital service corporation or medical service corporation that provides health insurance in Arizona. This law does not apply to any health plans that do not include coverage for out-of-network health care services.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

When balance billing isn’t allowed, you also have these protections:

• You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.
• Generally, your health plan must:
  • Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”).
  • Cover emergency services by out-of-network providers.
  • Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
  • Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you think you’ve been wrongly billed, contact 

• Visit The U.S. Centers for Medicare & Medicaid Services (CMS) at 1-800-985-3059 or visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
• The Arizona Department of Insurance and Financial Institutions at 1 (602) 364-3100.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.