DRG (Diagnosis-Related Group):
This is the way some insurance companies categorize inpatient hospital stays in order to standardize a payment to the hospital. Generally, a DRG payment covers all charges associated with an inpatient stay. These are typically categorized by diagnosis, treatment received and length of stay.
CPT (Current Procedural Terminology):
CPTs are a complex and uniform code set that is used to report medical services you receive. Your physician schedules your surgery with the CPT codes expected to be performed. After services are rendered, the codes are reviewed again to ensure that they accurately reflect the services performed. These CPTs are then sent to your insurance company where they determine how much to pay for each service provided.
Diagnosis codes are another code set that identifies the reason you need the services that are being performed. These codes can include diseases, disorders, symptoms and injuries that contributed to you needing to visit a physician.
In-Network and Out-of-Network:
When a provider is “In-Network” with your insurance that means they have contracted with your insurance provider to accept discounted rates for your care. “Out-of-Network” providers have not contracted with your insurance to accept discounted rates. The best way to check for this status is to call the customer service number on the back of your insurance card.
The amount you will pay for healthcare services before your health insurance begins to pay.
A fixed amount established by your insurance for sharing the cost of your care.
Typically given as a percentage, this is portion of the healthcare that you are responsible for paying. For example, 20% coinsurance means that you are responsible for paying 20% and your insurance will pay the other 80% once you have satisfied your deductible.
The most you will have to pay out of pocket on deductibles, co-payments and coinsurance. After you have met your deductible, you may be responsible for 20% of your healthcare until you have paid out your entire out-of-pocket. Some insurance include deductibles and co-payments in this accumulation but not always. Your insurance can clarify with you if these cross apply to each other.
A comprehensive list of hospital items/services that are billable to a hospital patient or a patient’s health insurance provider.
The dollar amount your insurance is expected to pay your provider for services rendered.
In compliance with federal rules, we have published our chargemaster below.
**It is important to remember that the charges reflected in our chargemaster do not represent your patient financial responsibility.
Your out-of-pocket costs are based on your individual health plan benefits applied to the negotiated rates we have with your in-network health plan.
If we are not in-network with your plan or you do not have insurance, we are happy to give you quote. For more information about your individual cost of care, please call us at 512-327-0000.