Shoppable Hospital Services Explained

What the CMS price transparency rule requires

The CMS Hospital Price Transparency rule (45 CFR Part 180) has applied since January 1, 2021. Under it, every hospital in the United States is required to publish a machine-readable file listing its standard charges for all items and services. Standard charges include the gross charge, the discounted cash price, payer-specific negotiated charges, and the de-identified minimum and maximum negotiated charges.

The rule has a second part aimed at ordinary readers rather than software, covered next.

What counts as a shoppable service

CMS describes a shoppable service as one that a patient can schedule in advance. The rule requires hospitals to present a consumer-friendly display of 300 shoppable services, or to offer an online price estimator tool instead. CMS specifies 70 of those services, and the hospital selects the rest.

When a hospital falls short, CMS has several enforcement tools available, including warning notices, corrective action plans and civil monetary penalties. For a closer look at the raw files, see how to use hospital price transparency files.

Why scheduled care is easier to compare

Planned services tend to have a clear start and end. A scan, a lab panel or a colonoscopy is a defined service with a defined code, which makes side by side comparison more practical. A few reasons:

• There is time. Because the service is scheduled, a patient can look up prices, ask questions and compare before the date arrives.
• The service is well defined. Billing codes generally describe the same service across hospitals, so the comparison is closer to like with like. The American Medical Association maintains CPT codes, each of which has five characters. See what CPT codes are for how this works.
• Estimates are possible. Scheduled services are the ones where a written estimate can be requested, as covered below.

Pages on this site follow that structure. Browse procedures or start with a hospital price page for a service such as an MRI in Houston, a CT scan in Miami and Fort Lauderdale or a colonoscopy in Tampa and St. Petersburg.

Why emergencies are harder to compare

An emergency is not scheduled, so the shoppable framework does not fit it. Few people can weigh a price list in the moment, and the final charges depend on what happens during the visit. Hospital emergency department visits are billed by level, and a bill can include separate charges for tests, treatment and physician services that are not known in advance.

If a medical emergency happens, the step to take is to dial 911 or head to the closest emergency room. This site does not advise on where to seek care. The ER prices shown here are hospital facility charges, not urgent care prices. For background on how the two kinds of bills differ, see ER and urgent care costs.

The No Surprises Act, which took effect on January 1, 2022, addresses part of the problem. For people with most private health plans, it 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. What a patient owes for those services is generally held to in-network levels. These protections do not extend to ground ambulance services.

What a posted price does and does not tell you

A posted price is a starting point, not a final bill. A few points help when reading one:

• Gross charges are list prices. They come from the hospital's master list, called the chargemaster. Many hospitals also offer a discounted cash price, while insurers pay negotiated rates. See what a chargemaster is and cash price versus insured rate.
• Facility fees are only part of the picture. Hospitals can bill a facility fee, while physicians such as radiologists and anesthesiologists usually bill a separate professional fee. Figures on Clear Hospital Costs reflect hospital facility charges drawn from each hospital's own files, so they do not represent total costs. More detail is in facility fee versus professional fee.
• Prices can differ between hospitals for the same scan. Why MRI prices vary walks through common reasons.

Pages for Texas, Florida and Tennessee show gross charges, cash prices and insurer negotiated rates by hospital, refreshed from the hospitals' files twice a week. Insurer rates can include Medicare Advantage and Medicaid managed care plans, and clear data errors are left out as described on the methodology page. Start from the Texas hub or the Florida hub.

Ways to get a firmer number before a scheduled service

Under the No Surprises Act, people who are uninsured or who choose not to use their insurance can get a good faith estimate of expected charges for scheduled items and services. A provider is expected to hand one over once a service is booked at least 3 business days out, or whenever a patient requests it.

Where the final bill from a provider or facility comes in at $400 or more above its good faith estimate, the patient may be able to turn to the patient-provider dispute resolution process. That process generally has to be started within 120 calendar days of the bill date. CMS runs a No Surprises help desk. Details are in the guide to the good faith estimate.

Other steps some people take include:

1. Asking the billing office for the self-pay price, as described in how to ask for the self-pay price.
2. Asking which billing codes will apply, then comparing hospitals using how to compare hospitals by price.
3. Asking about financial assistance, covered in hospital financial assistance. Nonprofit hospitals must meet IRS section 501(r) requirements, and each hospital sets its own eligibility rules.

With a high-deductible plan, a member often pays the plan's negotiated rate before the deductible is met. Whether a visit is billed as preventive or diagnostic can also change the cost, so the high-deductible plan tips may help frame questions for a plan and a hospital.