Facility Fees vs Professional Fees Explained

Why One Hospital Visit Can Bring Several Bills

Many people expect a single bill after a hospital procedure. In practice, a visit often produces more than one, and they may arrive on different days from different senders. The reason is that the hospital and the physicians who treat patients are frequently billed separately.

Two terms help make sense of this. A facility fee is what a hospital or hospital outpatient department can bill for the setting and resources used during a visit. A professional fee is what a physician bills for their own work. Surgeons, radiologists and anesthesiologists usually bill professional fees separately from the hospital.

What a Facility Fee Generally Covers

The facility side of a visit is about the setting and the resources around the patient. Depending on the service, a facility charge may reflect things such as:

• The procedure room or imaging suite and the equipment in it
• Nursing and technical staff employed by the hospital
• Supplies, and some drugs, used during the service
• Recovery or observation space

Hospital bills often list revenue codes, which point to the department or type of service. Inpatient stays are often paid by MS-DRG. To see how these labels appear on a real bill, the guide on how to read an itemized hospital bill walks through the lines one at a time.

What Professional Fees Cover

A professional fee pays for a physician's own work. A radiologist who reads a scan, a surgeon who performs a procedure and an anesthesiologist who manages sedation usually bill separately for that work. These bills may come from a physician group rather than from the hospital, so the name on the envelope can be unfamiliar.

Standardized codes often appear on these charges. The American Medical Association maintains the CPT system, in which each code has five characters. A second set, HCPCS Level II, is maintained by CMS and generally covers things like supplies, drugs and some services, which is why it can show up on facility lines as well. For more, see what CPT codes are.

Why the Prices on This Site Are Facility Charges

Clear Hospital Costs publishes hospital prices for Texas, Florida and Tennessee, taken from the hospitals' own files. These are hospital facility charges, not total costs. A figure shown for a scan or a colonoscopy does not include separate professional fees from the physicians involved.

The files exist because of the CMS Hospital Price Transparency rule (45 CFR Part 180), which has applied since January 1, 2021. Under it, every hospital in the United States must publish a machine-readable file listing its standard charges for all items and services. The file generally contains the gross charge, the discounted cash price, payer-specific negotiated charges, and the de-identified minimum and maximum negotiated charges. Our pages show gross charges, cash prices and insurer negotiated rates by hospital, refreshed from the files twice a week. Clear data errors are left out, as described on the methodology page.

Emergency visits follow the same logic. Hospital emergency department visits are billed by level, and this site shows hospital ER visit facility charges, not urgent care prices. A physician who treats a patient in the emergency room may bill separately on top of that facility charge. For background, see how ER and urgent care costs differ.

Reading Facility Prices Alongside Other Costs

A facility price is only one piece of the picture, but it can offer a common basis for comparing hospitals. Some options readers may find useful:

1. Look up a service on a procedure page, such as an MRI in Houston or a colonoscopy in Miami and Fort Lauderdale, and note the facility figures.
2. Ask the hospital or the physician's office whether the physician bills separately, and which groups may send their own bills.
3. Ask which codes are expected for the service, to match them to the facility listing.
4. For those paying without insurance, ask about the discounted cash price. The guide on how to ask for the self-pay price covers the conversation.

Insurance design affects how a facility charge turns into a patient bill. Under a high-deductible plan, a member often pays the plan's negotiated rate for a service until the deductible has been met. Many plans waive cost sharing for certain preventive services when they are delivered in network, so the same visit can cost a different amount depending on whether it is coded as preventive or diagnostic. See high-deductible health plan tips for more.

Estimates, Protections and Help With Bills

Several tools exist for seeing charges before a service or sorting out a bill afterward. Which ones apply depends on the situation.

• Good faith estimates. The No Surprises Act lets people who are uninsured, or who decide not to run a service through insurance, request a good faith estimate of the charges expected for scheduled items and services. Providers must give one when a service is scheduled at least 3 business days ahead, or when a patient asks. Because facilities and physicians are often separate providers, estimates may come from each of them. If a final bill from a provider or facility is at least $400 more than its estimate, the patient may be able to use the patient-provider dispute resolution process, which generally must be started within 120 calendar days of the bill date. Details are in the good faith estimate guide.
• Surprise bill protections. For people with most private health plans, the No Surprises Act, effective January 1, 2022, generally protects against surprise bills for emergency services, including at out-of-network facilities, and for certain non-emergency services from out-of-network providers at in-network hospitals and ambulatory surgical centers. Cost sharing for those services is generally limited to in-network levels. Ground ambulance services are not covered by these protections.
• Financial assistance. Nonprofit hospitals must meet IRS section 501(r) requirements, including a written financial assistance policy that is widely publicized. Eligibility rules differ from one hospital to the next, and many other hospitals also have assistance programs whose terms vary. See hospital financial assistance for what to look for.

When a bill seems unclear, some people request an itemized statement and ask questions line by line, which the guide to negotiating a hospital bill explains further. This guide is general information only and is not medical or legal advice. If a medical emergency arises, call 911 or head to the closest emergency room.