Price Transparency: Price Estimate and Downloadable List

 Call, Email, or Click for an Estimate

Saint Agnes supports price transparency and believes it is important for you to know what out-of-pocket costs you will incur for services provided at one of our facilities. We have established three easy ways for you to obtain estimate of your costs – call or email:

By calling (559) 450-7262, or email mybenefitadvocate@samc.com, we can give you an estimate of your out-of-pocket costs for a medical service or procedure.

We review:

• the specific service or procedure you will receive
• the physician providing the service
• your insurance, including what you have already paid towards your deductible 

Price Estimate Request

No Surprises Act – Good Faith Estimate

Uninsured and self-pay patients may request a good faith estimate. Learn more.

Helpful Definitions

Understanding health care terminology around price poses significant challenges for patients. If you ask a group of people to define what "price" is, it is likely you will get a variety of answers. Below are definitions to help frame understanding on this issue:

Charge: The dollar amount assigned to specific medical services before negotiating any discounts from payers. The charge is different from the price. Very few patients pay the charge regardless of their insurance status; and, therefore, this data is not meaningful to people.

Price: The negotiated and contracted amount to be paid to providers by payers (also called the "allowed amount"). A patient's out-of-pocket liability for health care services is based on this allowed amount. Note that the price for a given service varies by insurance plan as these are separately negotiated by plan/employer.

Out-of-Pocket: Portion of the price for medical services and treatment for which the patient is responsible. This includes copayments, coinsurance, and deductibles.

Cost: The definition depends on the cost being referenced: To the provider, cost is the expense incurred to provide health care to patients. To the employer, cost is the expense related to providing health benefits. To the insurance plan, cost is the price paid to the provider. To the patient, cost is the out-of-pocket fees.

Price Disclosure and Lists

The information contained herein is being provided in conjunction with the Centers for Medicare and Medicaid Services (CMS) price transparency requirements.  Hospitals are required to provide several different types of information for its standard charges as well as for a list of 300 items and services deemed “shoppable.”  A shoppable service is a service that can be scheduled by a healthcare consumer in advance.  

By clicking to download this price transparency information you agree you have read and understand the following:

1. Updates. The information contained in the file(s) is current as of the last upload. This information is subject to periodic changes and the file(s) will be updated and posted as soon as practically possible
2. Charges.  It is important to understand the distinction between two different types of charges prevalent in the healthcare industry. The first is “gross charge” that relates to the established prices that are billed to all patients regardless of insurance or health care coverage. The second is “negotiated charge” or prices the insurance companies and payers have agreed to pay for services (also known as the “contracted rate”). A patient with insurance or coverage typically is responsible for a portion of the negotiated charge which will vary based on benefits that are provided by the insurance companies and payers. The portion of the charge that a patient will pay a hospital for services is called the “out-of-pocket” expense (often as a copay or deductible amount or co-insurance)
3. File Contents.  The file(s) contain the gross charge, charge description, associated accounting/billing code (such as HCPCS, CPT, NDC, DRG, or other payer identifier) of the item or service as reflected in the hospital's charge description master or other internal sources for similar data and or charges from common services packages (collectively referred to as CDM).  The file includes five standard charge types required by the rule – either established and/or allocated – gross charge, discounted cash price, payer-specific negotiated charge, de-identified minimum negotiated charge, de-identified maximum negotiated charge. (Please also refer to Section 7 ‘File Layout Information’ below)
4. Additional Fees.  The gross charge represents the dollar amount assigned to specific medical services before application of any negotiated discounts to third-party payers. The actual hospital charges will vary based on the type of care provided, treatments, individual health conditions and other factors.  If you need an  estimate of your out-of-pocket cost, please call or submit a request online as described elsewhere on this website. PLEASE NOTE THESE CHARGES do not include fees from your physician, surgeon, anesthesiologist or other professional services billed by your physician(s) AND OTHER PROFESSIONAL PROVIDERS. Typically, you will be billed separately for these professional services.  Most displayed charges herein do include hospital services such as room and bed charges, including operating rooms, recovery rooms and treatment rooms.  Other charges such as medication charges, food service charges, anesthesia charges also are typically included with the surgical procedure or MS-DRG charge levels.  However, in certain circumstances, they may be displayed separately in charge files or on hospital bills  
5. Adjustments.  Following the CMS guidelines, the information posted represents the hospital’s current gross charges as reflected in the CDM. However, it is important to understand that the information represented in the CDM is the starting point in many cases and can undergo additional adjustments through the billing process, therefore, please be aware:
   
   1. The gross charge shown is the original charge for the item or service prior to any adjustments that result from applying modifiers in certain situations
   2. The CDM is used in multiple hospital departments and may have different charges for the same item or service and such instances will repeat in the file. For a single chargemaster item, the charge is consistent; however, there may be slight variation in charges for services with similar descriptions for various reasons 
   3. Gross charges for certain items or services are based on per unit, such as – including but not limited to – surgeries, anesthesia, and recovery which can be based on the unit of time and complexity; and medications, drugs which can be based on weight, dosage, age or packaging; etc.
   4. Certain items and or services have a zero-dollar price in the CDM for a variety of reasons – contracted billing services that drop charges externally, no cost supplies, investigational device or medication exemption items in clinical trials and studies, replacement for a recalled or defective device, explode codes and other system limitations.  Such items and services will appear with a zero-dollar charge and this charge is not reflective of the actual charge. In addition, items and or services are sometimes assigned a one penny price to reflect, for example, a state or federally provided medication or drug, contrast items, therapy status codes used for CMS reporting, etc. The charge that will appear on the bill may vary from the charges in the posted file(s)
   5. The file may also contain CDM items for non-charges (such as payments, allowances, transactions, etc.)
6. MS-DRG Information.  Note on MS-DRG related information: Prior calendar year inpatient discharges are grouped using the current year CMS MS-DRG. The current Medicare year's geographic mean length of stay (LOS) and description is used. The current year is used if the same MS-DRG is present in two Medicare periods.  Charges are calculated and displayed by DRG by taking the total charges divided by the total case volume per DRG.  Charges are listed for acute inpatients and newborn accounts. The charges to patients with all insurances and payers were included in calculating the charges per DRG. Charges to Rehabilitation and Long-Term Care accounts have been excluded. Also excluded are charges related to error MS-DRGs 0, 998, 999. Individual cases where LOS is greater than the Geographic Mean LOS times 1.5 are excluded. Low volume DRGs where number of cases were < 10 and high dollar outliers are also excluded
7. File Layout Information. The information provided herein is as required by The Centers for Medicare & Medicaid Services’ Price Transparency Final Rule and is not a guarantee of final billed charges, which may vary from these estimates for many reasons including the individual patient’s unique medical condition, complications, unknown circumstances, other diagnoses and recommended treatments. Moreover, these estimates may not include professional fees such as physician, radiologist, anesthesiologist, and pathologist fees. The insurance benefit information (where applicable) is based on information provided by insurers which may not be current on the date of a scheduled procedure, and benefits and eligibility are subject to change and are not a guarantee of payment: 
   Chargemaster – Tab to display chargemaster (normally a 4-5 column extract) includes gross charges 
   Standard Charges - Tab to display Standard Charges. Includes all five charge types required by the rule – either established and/or allocated – gross charge, discounted cash price, payer-specific negotiated charge, de-identified minimum negotiated charge, de-identified maximum negotiated charge – when available 
   Shoppable Services – Tab to display Shoppable Services. Includes the 70 mandated by CMS and at least 230 additional services selected by the hospital except for when a hospital doesn’t provide the required number services. All five charge types required by the rule – either established and/or allocated – gross charge, discounted cash price, payer-specific negotiated charge, de-identified minimum negotiated charge, de-identified maximum negotiated charge 
   Additional tabs: 
   Description – Consumer friendly description of service, item or pharmaceutical 
   Code – Can contain CPT/HCPCS, MS-DRG or APR-DRG Code (note: all APR-DRG’s are displayed as 3 numbers to distinguish from other codes and end in X to signify severity) 
   Type – Outpatient (CPT/HCPCS) or Inpatient (MS-DRG or APR-DRG) 
   Gross Charge – Charge for an item or service 
   Discounted cash price – The discounted cash price information is subject to hospital-specific policy guidelines for financial assistance discounting. Patients can determine their eligibility and associated discount by contacting the hospital 
   De-identified min contracted rate – The minimum derived contracted rate across all payors (All payers) 
   De-identified max contracted rate - The maximum derived contracted rate across all payors (All payers) 
   Derived contracted rate - The median derived contracted rate across all payors (All payers)