There are lots of ways this guide might help you make decisions about medical procedures and insurance.
- An uninsured consumer may be able to get an idea of the cost of services before having a procedure done, and may even opt to have it in a different region, depending on the difference in costs.
- An uninsured person may use the average amounts as a baseline to shop among providers.
- An uninsured consumer may also be able to get an idea of how far down the providers come from the billed amount by looking at the difference between the billed, contracted, and paid amounts. An uninsured person may then be able to negotiate a lower amount to pay with the provider, similar to the way that insurance companies negotiate lower rates.
- A patient with insurance may be able to determine an estimated coinsurance amount.
This consumer information guide is the result of Senate Bill 1731, 80th Legislative Session. The idea behind the bill was that cost transparency would reduce costs for consumers. The law requires the Texas Department of Insurance (TDI) to collect data from health plans to determine how much they pay doctors and hospitals for specific medical services. It also requires TDI to combine all responses and present summary information based on the 11 Health and Human Services regions in Texas. This guide currently contains 2013 reimbursement rate data, and TDI will update this information annually.
While there are thousands of CPT codes representing many different medical procedures, this Health Insurance Reimbursement Rates Consumer Information Guide has data for 439 CPT codes representing common procedures. If a CPT code is not listed on this guide, TDI does not have reimbursement data for it. FAIR Health Consumer is a nonprofit organization that has medical cost data that can be researched by CPT code. If you are unable to find data for a specific CPT code on this guide, billing data can be looked up on the FAIR Health Consumer website, located at http://fairhealthconsumer.org/
This guide provides data using the 11 Health and Human Services regions in Texas. You can find your region using your city or county on the Search page. A region map and a list of the counties within each region are also available on the Find Your Region page.
Provider availability is probably the most significant factor in determining the prices in a region. The cost of living and amount of uncompensated care are other factors.
This guide provides data using Current Procedural Technology (CPT) codes and Medicare Severity Diagnosis Related Group (MS-DRG) codes. These are the codes commonly used by doctors' offices, hospitals, and insurance companies. A list of available CPT and MS-DRG codes and code descriptions is available on the Specialties & Codes page.
These are the standardized numbers used to identify the specific medical services a physician provides to a patient. Health plans use these codes to determine how much they will reimburse the physician for a medical claim. CPT is a registered trademark of the American Medical Association.
Some medical procedures require a physician's services and the use of technical equipment. In these cases, the following modifiers (extensions) can be added to the end of the standard five-digit CPT code to separate these costs.
- *26 - A modifier used to specify the professional component (portion) of a medical service.
- *TC - A modifier used to specify the technical component (portion) of a medical service.
These are standardized numbers used to identify medical services provided by a hospital. Hospitals use these codes to group patients who have similar clinical characteristics. Health plans use these codes to determine how much they will reimburse the hospital for a patient's medical claims.
Since these codes are linked to a fixed payment amount, hospitals and health plans try to group patients into categories based on the cost of their care. Two important factors that contribute to cost of care include additional health problems that result from treatment (complications) and a patient's unrelated illnesses or diseases that are present at the time of treatment (comorbidities).
For this guide, TDI has classified medical services based on the type of doctor or the location where the service is provided. This guide includes the following medical categories:
- Professional Services - General - Medical services that are commonly performed or routine in nature, including office visits, emergency visits, and vaccinations. This category also includes miscellaneous obstetric, cardiologic, and chiropractic services.
- Professional Services - Pathology - Medical services to detect or diagnose a disease, including blood tests, urinalysis, tissue analysis, and other screenings.
- Professional Services - Radiology - Medical services to diagnose or detect illness or injury, including CT scans, MRIs, MRAs, PET scans, mammograms, ultrasounds, X-rays, and bone density measurements.
- Professional Services - Outpatient Health Care Claims - Doctor's charges for medical services performed on an outpatient basis, when the patient is not formally admitted to a hospital, surgical center, or similar facility. The patient receiving these services may be on observation status. This includes charges for orthoscopic surgery, biopsies, exams, and removal of certain tissues.
- Institutional Provider - Outpatient Health Care Claims - Facilities' charges for services performed on an outpatient basis, when the patient is not formally admitted to a hospital, surgical center, or similar facility. This includes charges for procedures such as orthoscopic surgery, biopsies, exams, and removal of certain tissues.
This guide allows users to view data two ways. You can choose to view data for a specific CPT/MS-DRG code in a selected specialty, or you can view data for all of the available CPT/MS-DRG codes in the selected specialty. In cases where you aren't sure exactly which procedures might be needed, or if you might need more than one procedure in a specialty, you might want to view all. One example would be when a family is expecting a baby. In this case, choosing to view all in the category of neonatology would display several procedures that might be of interest.
Health care services performed by physicians or hospitals that have agreed to provide medical care for members of a health plan at a negotiated rate. This term includes physicians or providers that are members of a Health Maintenance Organization's (HMO's) delivery network or a Preferred Provider Organization's (PPO's) preferred provider network.
Health care services performed by physicians or hospitals that have not agreed to provide medical care for members of a health plan at a negotiated rate. An HMO plan usually only pays for care received from within its network, and a PPO plan requires members to pay more to receive out-of-network services.
The average dollar amount physicians or hospitals bill to health plans for a specific CPT or MS-DRG code. This amount is presented on a per-claim basis.
The average dollar amount health plans actually pay to providers as reimbursement for a specific procedure or service. This amount does not include the patient's cost-sharing requirements (applicable deductible, copayments and/or coinsurance), and it is presented on a per-claim basis.
The average dollar amount health plans agree to pay to in-network providers as reimbursement for a specific procedure or service. This amount only applies to in-network claims, and it is usually established by contract between health plans and providers. This amount includes the patient's cost-sharing requirements, and it is presented on a per-claim basis.
The average maximum amount health plans will consider for payment to out-of-network providers as reimbursement for a specific procedure or service. Since no provider contract is in place, the health plan determines how much it is willing to pay based on an internal formula. The provider may "balance bill" the patient for the difference between the provider's billed charges and the amount paid by the health plan.
Additional helpful information for consumers is available on the TDI website as follows:
- Consumer Guide to Health Care Billing - Provides information about balance billing and tips for consumers: http://www.tdi.texas.gov/consumer/cpmbalancebilling.html
- Texas Health Options - Provides assistance for consumers shopping for health insurance coverage: http://www.texashealthoptions.com
- Your Health Care Coverage - TDI publication that provides information about types of health insurance, dependent coverage, pre-existing conditions, health plan costs and benefits, and related information:
For technical questions or other issues involving the use of this application, contact: ReimbursementRates@tdi.texas.gov