A few months ago, I took a bad fall and split my chin open. Nothing major—just needed a few stitches. I head to the ER, they clean it up, throw in a couple of sutures, and send me on my way. No big deal.
Then the bill comes. ~$5,300.
For 4 stitches.
I thought it had to be a mistake. I called the hospital. Nope, that’s the “standard charge.” Insurance knocked some of it down, but without even knowing what I was supposed to pay, I had zero leverage to negotiate.
So I started digging. Turns out hospitals pull these prices out of thin air. The same procedure can cost 10x more depending on where you go. Insurance companies negotiate lower rates, but if you’re uninsured or just don’t know the real cost, you’re screwed.
Bruh get vet bond for next time. It’s super glue meant for closing wounds. I have really good health insurance and there is no way in heck I’m going to the er for something so minor. I busted above my lip all the way thru most recently, you could see my gums thru the slit. I just freaking glued it. You gotta handle your business or get use to paying giant bills for no reason. People been alive way longer without doctors than with them.
lol - I am currently 3 weeks into nursing a cut on my heel that I chose to superglue rather than face a massive hospital bill (happened late at night). it’s been a struggle to keep it from ripping back open, and I’ll end up with a pretty good scar I’m sure since I couldn’t really knit the pieces back together right. luckily I avoided any infection by being really careful, flushing it out, etc. - but still bs that I can’t even get basic medical care for an injury after paying $1k/month insurance premium 😕
I work for a health system in revenue cycle… that is why I recommended commercial reimbursement rates. Medicaid and Medicare is the reason that everyone else ends up subsidizing the cost of healthcare. Hospitals will not settle for Medicaid reimbursement.
I believe by law you have to publish the top 5 contracted rates on the hospital websites as part of price transparency. You will have to build a utility to scrub every hospital website and download the files ( they are in machine readable format)
Every hospital must, by law, publish a machine-readable file of ALL of their rates, by CPT/DRG, for each contracted payor, along with their billed charges. It must be accessible on their website (though hospitals go to some lengths to obfuscate where the file is located). Note that ‘machine readable’ doesn’t mean that you can open it directly. These files can be quite large and typically require some facility with database software or Excel, but the data is out there. DM me if you interested in more. I can also provide some enlightenment on how Medicare rates are calculated and where the appropriate public websites are located.
Your professional fees/provider billing is ER physicians; hospitalists; radiologists; anesthesiologists; pathologists; cardiologists; etc. The doctors bill separately from the facility/hospital and are not required to publish their rates.
The Hospital Price Transparency regulation defines several types of standard charges, including:
Gross charges (as found in hospital chargemasters, which is the list of all individual items and services maintained by a hospital for which the hospital has established a charge, absent any discounts);
Discounted cash prices (the charge that applies to an individual who pays cash or cash equivalent for a hospital item or service); and
Charges negotiated between the hospital and third-party payers.
Hospitals are required to make these standard charges public in two ways:
(1) A single comprehensive machine-readable file with all standard charges established by the hospital for all the items and services it provides.
(2) A consumer-friendly display of standard charges for as many of the 70 CMS-specified shoppable services that are provided by the hospital, and as many additional hospital-selected shoppable services as is necessary for a combined total of at least 300 shoppable services. This requirement can be satisfied through the release of a shoppable services file or by offering a price estimator that generates a personalized out-of-pocket estimate that takes into account the individual’s insurance information.
I encourage you to check out the podcasts "An Arm and a Leg" and KFF's "What the Health?" for conversations on this exact topic.
IN short - it's private information. The first Trump administration tried to make the prices hospitals charge public to encourage competition but health systems hvae done their best to make the information inaccessible and confusing.
That is a great point. Imagine a healthcare system trying to defend why they wouldn’t provide care to our Seniors in the community. Also it’s not the young people that consume healthcare, it’s the older population. It is not just a simple answer of not accepting Medicare. You do see physicians providing concierge care in high income communities because they don’t want to deal with billing insurance commercial or Medicare.
I agree we should provide charity care to those who actually need it, but retired Boomers are the wealthiest demographic in America. Walk me through why you believe a minimum wage Walmart cashier with employer insurance should pay inflated prices for health care in order to subsidize a retired millionaire on Medicare.
The average boomer is very much dependent on social security and does not have money to pay for healthcare. According to Transamerica Center for Retirement Studies, the estimated median retirement savings for baby boomers is $202,000. Would you qualify that as been rich?
If the median retired Boomer can't afford to pay for healthcare, then we should help them. We do not need to help the wealthiest retirees at the expense of younger workers.
What we should not do is allow United Healthcare and Aetna and Cigna to hoover up all of the funds in the Medicare program with their Medicare Advantage bullshit plans.
If you’ve ever said that private companies operate more efficiently than the federal government, you don’t know jack about Medicare.
So you took an ambulance? Hospitals of course are different than a normal business. They have to be ready all the time. In my state they find part of the hospital costs differently. The hospitals get paid a flat rate to just be there and then the state negotiates the rate for all other stuff. It’s still not cheap but part of the hospital costs are in our monthly insurance and the rates if something happen are lower.
I don’t know if your insurance has a lower negotiated rate but it’s always higher cause you are paying for all the other stuff you didn’t use.
You're not being billed for the stitches, you're being billed for using the ER. There's a base fee charged to everyone seeking care, which helps cover the costs of basic supplies that aren't billed separately, the cost of staffing 24/7, the cost of equipment, and so on.
For future reference, most urgent cares can handle stitches, and the cost would generally be less than $250.
I know a guy who was self funding a knee surgery He called five hospitals had them all bid for cash price. Had access to blue cross and Medicaid reimbursement rates. ( former insurance exec )
Providers already have different self pay rates and discounts. There are also FPL discounts and other things. People just unfortunately don’t know to ask for them.
You can do this for anything. Even if you have a commercial insurance…you can still chose to pay a self pay rate. Most hospitals just don’t want you to know this.
Hospitals do not care if you know this. Honestly it much easier and more beneficial for them instead of the army of people they have to hire to get paid by insurance companies. A smaller scale example of this would be the huge growth in direct primary care which essentially just bypasses insurance. Patient gets cheaper care and better care, physician gets paid more. Wins all around.
Contracted rates are lower b/c it’s guaranteed. They don’t have to pay millions of dollars in re-billing and negotiations.
Those amounts aren’t pulled out of no where, they look at services happening and cost to stay open. You aren’t just paying for the materials and the 1 hour the doctor saw you, you are paying for there to be a doctor and clinic at all, plus the billing system. Higher costs for those not in contracts do reflect a whole lot of costs the occur specifically because not contracted.
All the ppl against universal health care as they don’t want to pay for others- but you already are
But yea, your bill is covering extra costs due to no contract. Instead we should all have contracts. It’s a mess.
My cousins son, had to get 3 stitches in his knee. His bill was around the same! Sucks when er is only choice when it’s after hours, and have no other choice due to bleeding, that won’t stop!
Any chance you could add medicare rates to the tool? That's a much more common reference point. No provider is going to accept medicaid rates from some rando.
I am American but studied abroad, and on my final day of study abroad I fell and had to get stitches. Didn’t pay anything. They didn’t ask me for identification or anything…just stitched me up and sent me on my way.
Probably paid hundreds of dollars for the stitches removal that I had done a week later at an urgent care in the US.
This is such a great service! However, there are pre negotiated billing prices for most states based on if the patient is using health versus auto insurance. Normally, the out of pocket rates for uninsured patients are much cheaper and are negotiable.
Are your rates based on insurance, no-fault, or workers comp fee schedule? If any of those, how will this positively impact uninsured patients?
Thanks for the kind words! This tool is only based on government-set rates (medicare, VA, medical) and hospital sticker price, so these might not reflect the actual lowest prices patients can negotiate.
Its hard to get private insurance rate data, are no-fault or workers comp fee schedule data publicly available?
Check workers comp scheduled rates which are publicly available for NY; and other states. Private insurance rates aren’t normally available to your point but look at NY as an example to see schedules. Considering it’s one of the most expensive states in the country (USA), should be a good indicator of rates and cost.
Hospitals tend to lose money and their put patient facilities make up for them. Also you get other grants and things fro. The government. It's not every medicare patient every time but it does not help especially the rural Hospitals.
Interesting that private practices can stay afloat while being paid half what hospitals are paid by Medicare. What’s not acceptable is the government paying 2x for the exact same thing. It’s not our responsibility to keep hospitals afloat if their bloat isn’t financially sound. And the typical rate hospitals receive from commercial is over 200% Medicare.
A hospital emergency room ends up on the hook for a lot of charity care (between EMTALA and Hill-Burton). Medicare and Medicaid don’t pay that well either, but usually the unfunded mandates and liability define the high price of care in a hospital ER.
Private independent clinics can, in theory, stay afloat, but most of them are being bought up by venture capital/private equity or even the insurance companies themselves. A doctor hanging a shingle these days really only works with DPC or cash pay.
Oh no, they exist. That’s a separate issue that you can lobby Congress about. Meanwhile hospitals continue on their merry way overcharging patients, employers, and the government for more typical outpatient services.
Again, that is purely a consequence of EMTALA and individual choices, not the hospital. If people use the ER like a PCP, and the hospital cannot turn them away, what do you think happens?
They don’t get paid if they can’t collect. You can’t get blood from a stone. As a result, the cost of uncompensated care and high liability is redistributed to those who can pay.
Private practices either barely or don't stay afloat. There aren't many left where I live because they've had to sell out to health systems. I've worked with private practices for years and personally know providers that have had to take loans or pay employees out of their personal pocket to make payroll.
Non private equity hospitals are not necessarily different from private equity. Some are operating on thin margins, while others enjoy large margins. Regardless, it makes no sense to pay those entities 2x for the same service. That payment structure has allowed for consolidation of the market and higher costs.
It means you can look up online what Medicare pays for any specific thing. The hard part is knowing WHAT will actually be billed. There are CPT codes for everything - from a simple office visit, to a vaccination (actually there's dozens of vaccination codes, for different vaccinations), to everything.
You can ask for an estimate, even at the ED, which will contain the codes they will most likely bill you. Obviously this is going to work in more urgent scenarios, but for something like OPs stitches, it’s worthwhile. Hospitals are required to give an estimate, for most services, anyhow (ED being a bit different, but if you ask, they are required,)
Nope, its not made up. Please don't negate my experience. I made this tool completely free with no signups, signins or any kind data retention since I needed it when I analyzed my bill. I hope somebody finds it useful. Moreover, I learnt a ton about other datasources to use from this discussion, which I am integrating with now. Peace!
Fairhealth.org is great but I couldn't search across city, county, state or nationally. I want to be as granular as I want to be, not pigeon hole to a zipcode that might have subpar hospital data. Have you found a way around this?
It was definitely interesting to look at this after my insurance was billed over 100k for a routine gallbladder removal. I didn’t stay overnight, just a simple day surgery. I haven’t received my final bill yet but ugh.
What your insurance will be billed is vastly different than just base rates out there. Also, if you have a commercial insurance you cannot compare it to Medi-Cal/Medicare.
Additionally, if this was a planned surgery (gallbladder often isn’t, but some are) you should have been provided an estimate prior. Even if it wasn’t planned you or a family member still have a right to ask for one.
Michigan is a ‘special’ place for two reasons: Union health plans have a LOT of bargaining power with insurers like Blue Cross. Blue Cross of Michigan had ‘most favored nation’ language in their contracts that guaranteed that if a hospital offered a better rate to United or CIGNA or Aetna, for example, that Blue Cross of MI would be entitled to those rates, too.
That kept rates artificially low in MI for years. If you compare commercial rates in MI with those in IN (right next door), you’ll see the stark contrast.
I believe Blue Cross of Michigan lost (or settled) an anti-trust case a few years ago because of the ‘most favored nation’ clause and had to pay Michigan doctors and hospitals.
My son hit his chin on the side of a pool in So Cal, we had just moved there so off to the ER. 6 hours later I told them we were leaving and they were really angry about it. I told them I should have just put butterfly stitches on it, as I was watching it heal while waiting. Damn CA. Lucky for the they never charged me.
The rates are also different in different states which i find crazy. Went to the er in florida for stitches and wasnt charged a dime. That would be like a $2-500 visit anywhere else.
I guess the obvious question is why did you go to the emergency department if it was just a few simple stitches? Your primary care physician or an urgent care can manage this for a fraction of the cost. An emergency department is for… emergencies. Unsurprisingly it costs a lot of money to keep everything stocked, staffed, and at the ready for those emergencies.
It was 1am at night, I was bleeding heavily and I don't have a car. The nearest facility is the ER. No urgent care clinics were open. My friend was assisting me and I was in shock, he did the best he could in that situation.
I thought it was ‘nothing major, just needed a few stitches’? I guess that’s code for middle of the night, bleeding profusely, in shock. I am not saying $5300 is a reasonable price, but don’t be disingenuous. I hope even you realize that the actual tangible output (4 stitches) is not the true cost of the service.
Providers typically overcharge insurance to try and get as much as possible from insurance, but insurance pays what they anyways pay. The issue happens when the insurance just denies the claim and the provider comes after you with the SAME bill, not the self-pay bill. That is just evil.
I would add the cash pay rate which is usually on the charge master data. Looking like you might not be pulling actual insurance rates either I looked up 72141 and there is no way insurance is paying 6k for a scan. There is usually a negotiated rate in addition to the insurance billed rate.
Thanks! I don't plan to monetize this since it's a public good, the data is free (Hospital Transparency Act) and our government should have something like this that is user friendly. However I do need to pay server costs, especially so if I slurp up private insurance data, so brainstorming ways to do that!
Yeah, hospitals really do make up the charges. Last year my idiot brother was hospitalized twice with medical bills and charges totaling over $1.1M. His insurance company (Aetna) paid a little over $27K against these bills. This silly game they play is so ridiculous, it’s funny.
Spot on. They charge some absurd amount over insurance negotiated rate and then collect as much from insurance as possible. If insurance doesn't pay, they came after the patient, which is evil..
You have no idea what you are doing. All of the information is out there if you want it. Every hospital publishes their rates with all of the insurers. They even include their cash price for uninsured patients. Every insurer publishes their rates with all of the hospitals and physicians. It’s all public, and free, and it’s massive amounts of data.
Yes exactly, and I want all of it in ONE place! Not in 100 excel sheets! I don't want to sift through 100s of urls to get all this. My time is precious.
If you have a commercial insurance, it’s not necessarily as cut and dry as just a simple rate. You may be looking at case rates, different pricing due to length of stay. Might be a % of charge; might have some stop loss logic. Commercial payment all comes down to the contract language between the insurer and provider/hospital.
Have you tried negotiating with them based on Medicare rates? I can help you convert your 6 page itemized bill into a format that can append the Medicare rates for each CPT code. That way, you can just send them that version and ask to atleast match it before going to collections?
My god. And this is the problem. A service should have a price, not a variety of prices depending on whatever. What if we went to the grocery store and there were 15 prices depending on who you are. Geez. I know you didn't create this problem. Just saying.
I mean that is how grocery store pricing works. But it’s per store and what pricing they get with their supplier. It’s why something like eggs can be cheaper at Trader Joe’s and cost 20 dollars more elsewhere.
Sure, but even their price could still vary day by day. And TJs is aimed at more middle class folks. Somewhere like Whole Foods or Gelson’s-where eggs will be more-and that is aimed at a higher spending market will cost more. Same situation with insurance and hospitals. Hospital pricing in an urban area is vastly different that that in a suburban area. Even for Medicare and Medical rates-it’s not the same across the board.
OP would need to pull the factors that go into determining each hospitals flat Medicare rates, to correctly determine even Medicare pricing for each hospital. The factors and calculations are published on the CMS site-largely based on location, population, services provided, trauma 1 vs trauma 3 etc etc. Most people just don’t realize it’s not just a flat rate, even for Medicare.
People need to develop skills we've lost our skills over time we can't even take care of ourselves without the government anymore it's very sad my goal in life is to do everything that nobody else is doing stitches should be done at home it's not rocket science and I promise you having a degree doesn't mean a whole lot when it's experience that actually teaches you that applies to everything in life most people are scared to work on their car will have you ever met Joe Schmo alcoholic who is a professional it's not that hard people if any human can do something you can do it too
Typed in one code on hospital bill for $1,320…Medical 2025 rate is $42.83/$42.88.
Uh…what now? They keep threatening to send me to collections lol. I feel like I’m in a good position now with the Medical rate and this was a hospital literally in California.
Entire thing was a scam I was there for 5 minutes and they completely dismissed my problem and then gave me discharge papers in the waiting room before even seeing anybody. Glad I finally have some proof this bill is crazy.
Just because you don't understand medical pricing doesn't mean it's crazy. These numbers aren't scams nor are they pulled out of thin air like OP claims. There are formulas that make sure facilities and providers are reimbursed fairly.
What are you even talking about? I have discharge papers prove I was in and out in 15 minutes and never made it past the waiting room and you think it’s valid the hospital wants to charge me $1,500 for that? In addition medical only pays <$100 for? I literally had to go to another hospital which admitted me for 4 days immediately after because of the entire thing, I could sue.
Reimbursed fairly??? Fairly for doing what? I wasn’t seen by anybody, they didn’t assess anything. I sat in the waiting room for 15 minutes.
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u/IntelligentSample489 Feb 07 '25
Should have just used super glue.