From 500 to 15,000+: A Guide to Mastering Your Healthcare Decisions Using the Enhanced Price Transparency Tools

As of January 2024, government mandates now require all commercially insured members have access to a tool that estimates their out-of-pocket expenses for almost any medical procedure.

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This change marks an astonishing 2900% increase from the most commonly sought-after "shoppable 500 services" that were available in 2023. While this might seem overwhelming at first glance, it's actually an empowering leap forward. It means taking control of your medical expenses has never been more accessible. 

But let’s be real here—many people, particularly men, often limit their healthcare visits to just an annual wellness exam and rarely explore other services. Navigating the healthcare system can be overwhelming due to the scope of services and the complexity of healthcare delivery. It’s like if you had to buy a car by choosing every part from a massive catalog of technical names without having any clue how they all fit together to create the finished product. 

That's why we’re here to provide your ultimate guide on how to best use the enhanced healthcare price transparency tools. It's time to take charge of your healthcare expenses with confidence. 

1. Understand How the Tool Works: 

To put it simply, healthcare price transparency tools act as expansive databases that gather network-negotiated price information for different healthcare providers. They use specific codes to list a wide array of medical services and treatments, now encompassing over fifteen thousand options. These codes are governed by the American Medical Association (CPT), the US government (HCPCS),or the American Hospital Association (Revenue Codes). 

When you search for a specific service using these tools, they provide personalized estimates for the cost, including what you may expect to pay out-of-pocket from different providers, considering factors like your location. It's important to understand that there may be various procedure codes for the same service, which can produce different cost estimates, reflecting potential differences in the specific approach, amount of time, or place of service for that service. Understanding this will help you get the most accurate estimates for the care you may need. 

2. Define Your Needs:

The number one most helpful piece of advice you can receive is to get the specific procedure codes that are likely to be performed and where they are likely to be performed (the place of service – like a hospital, outpatient location, ASC, etc.) directly from a medical provider. More specifically, directly from a medical provider that may perform the service or is already scheduled to perform the service. It is your right to have that information upfront.

Tip: It’s best to ask the front desk staff as they, or other billing staff, are the ones to put together the medical bill with the codes you need.

Having the actual codes will make the search process much simpler and more accurate. If you have them, great. If not, the tool will still help guide you to the right code(s) as best as possible. You may also want to have a list of providers you’d like to compare upfront. When you have the information you need, you can then choose if you want to search by service, by provider, or by specialty to get your supporting estimate(s).

3. Compare and Contrast:

Once you know the service you need, the tool can show you estimated costs from different providers. If you’re still in the consideration process, you should compare these prices, considering factors like distance from you and what maybe included in the service. This comparison can help you make a choice that fits your healthcare needs and budget. 

4. Delve Deeper:

Beyond costs, explore additional details that may be available to you outside the tool. Consider reaching out to different providers and getting appointment availability, reading reviews, checking quality ratings, and understanding any additional services needed. This comprehensive view helps you evaluate the value beyond just the price.

For more advanced procedures, find out if you have a choice in where the service can be performed, as some surgeons have admitting rights in multiple locations(those facility fees can be significantly different). You should also understand if there are lab or imaging services needed beforehand or therapy after the fact. Those are further expenses that you may also want to shop around.

5. Plan Ahead:

Using the tool empowers you to plan ahead for certain healthcare expenses. With estimated costs at your fingertips, you can budget accordingly and anticipate potential out-of-pocket expenses. This proactive approach can allow for better financial preparedness.

6. Consultation is Key:

While the tool offers estimated costs, remember that these are for reference purposes and may vary. For accurate pricing and detailed information, don't hesitate to speak directly to the providers ahead of your appointment and during your appointment. By sharing your cost estimate during a consultation with the provider, you’ll receive better clarity and ensure you understand exactly where your healthcare dollars are going.  

To see this all in action, check out our video on How to Use the Price Transparency Tools to Make Confident Healthcare Decisions.

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Leveraging Expanded Healthcare Price Tools for Consumer Empowerment

The expanded price estimation tools offer a substantial advantage for consumers managing healthcare expenses. With a broader array of services available, these tools serve as indispensable assets, providing personalized estimates that empower you to navigate healthcare costs more effectively.

As a consumer, it’s crucial to remember that you have a right to access a price estimation tool as well as to ask your medical provider for codes and costs directly, prior to a service being rendered. By embracing this opportunity to generate estimates and engage directly, you can exercise your rights and foster transparency and understanding within your healthcare transactions. This will continue to pave the way towards a fairer, more transparent healthcare experience.

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Mark Stamper is the Vice President of Commercial Products at Opyn Market^®. Having spent 20+ years in the healthcare industry, he is passionate about empowering consumers to take charge and feel good about their healthcare decisions, for the first time.

You can reach him at mstamper@myopyn.com.