Beginning Jan. 1, 2021, every hospital operating in the United States is required to provide clear, accessible pricing information online about the items and services they offer.
The information contained herein is being provided in conjunction with the Centers for Medicare and Medicaid Services (CMS) price transparency requirements. Hospitals are required to provide numerous different types of information for its standard charges as well as a list of 300 items and services deemed “shoppable.” A shoppable service is a service that can be scheduled by a healthcare consumer in advance.
Before clicking to download this information, please read and comprehend the following:
- Updates. The information contained in the file(s) is current as of the last upload. This information is subject to periodic changes and the file(s) will be updated and posted as soon as practically possible.
- Charges. It is important to understand the distinction between two different types of charges prevalent in the healthcare industry. The first is “gross charge” that relates to the established prices that are billed to all patients regardless of insurance or health care coverage. The second is “negotiated charge” or prices the insurance companies and payers have agreed to pay for services (also known as the “contracted rate”). A patient with insurance or coverage typically is responsible for a portion of the negotiated charge which will vary based on benefits that are provided by the insurance companies and payers. The portion of the charge that a patient will pay a hospital for services is called the “out-of-pocket” expense (often as a copay or deductible amount or co-insurance, also referred to as “patient-cost-sharing”).
- File Contents. The file(s) contain the gross charge, charge description, associated billing code (such as HCPCS, CPT, NDC, DRG, or other payer identifier) of the item or service as reflected in the hospital's charge description master (referred to as CDM). The file includes five standard charge types required by the rule – either established and/or allocated – gross charge, discounted cash price, payer-specific negotiated charge, de-identified minimum negotiated charge, de-identified maximum negotiated charge. (Please also refer to Section ‘File Contents’ below).
- Additional Fees. The gross charge represents the dollar amount assigned to specific medical services before application of any negotiated discounts to third-party payers. The actual hospital charges will vary based on the type of care provided, treatments, individual health conditions and other factors. If you need an estimate of your out-of-pocket cost, please call or submit a request online as described elsewhere on this website. Please note charges do not include fees from any hospital non-employed physician(s), surgeon(s), anesthesiologist(s) or other professional services billed by your physician(s) and other professional providers. Typically, you will be billed separately for these professional services. Most displayed charges herein do include hospital services such as room and bed charges, including operating rooms, recovery rooms and treatment rooms. Other charges such as medication charges, food service charges, and anesthesia charges also are typically included with the surgical procedure or MS-DRG charge levels. However, in certain circumstances, they may be displayed separately in charge files or on hospital bills.
- Adjustments. Following the CMS guidelines, the information posted represents the hospital’s current gross charges as reflected in the CDM. However, it is important to understand that the information represented in the CDM is the starting point in many cases and can undergo additional adjustments through the billing process, therefore, please be aware:
- The gross charge shown is the original charge for the item or service prior to any adjustments that result from applying modifiers in certain situations
- The CDM is used in multiple hospital departments and may have different charges for the same item or service and such instances will repeat in the file. For a single chargemaster item, the charge is consistent; however, there may be slight variation in charges for services with similar descriptions for various reasons
- Gross charges for certain items or services are based on per unit, such as – including but not limited to – surgeries, anesthesia, and recovery which can be based on the unit of time and complexity; and medications, drugs which can be based on weight, dosage, age or packaging; etc.
- Certain items and or services have a zero-dollar price in the CDM for a variety of reasons – contracted billing services that drop charges externally, no cost supplies, investigational device or medication exemption items in clinical trials and studies, replacement for a recalled or defective device, explode codes and other system limitations. Such items and services will appear with a zero-dollar charge and this charge is not reflective of the actual charge. In addition, items and or services are sometimes assigned a one penny price to reflect, for example, a state or federally provided medication or drug, contrast items, therapy status codes used for CMS reporting, etc. The charge that will appear on the bill may vary from the charges in the posted file(s).
- The file may also contain CDM items for non-charges (such as payments, allowances, transactions, etc.)
- MS-DRG Information. Note on MS-DRG related information: Prior calendar year inpatient discharges are grouped using the current year CMS MS-DRG. The current Medicare year's geographic mean length of stay (LOS) and description is used. The current year is used if the same MS-DRG is present in two Medicare periods. Charges are calculated and displayed by DRG by taking the total charges divided by the total case volume per DRG. Charges are listed for acute inpatients and newborn accounts. The charges to patients with all insurances and payers were included in calculating the charges per DRG. Charges to Rehabilitation and Long-Term Care accounts have been excluded. Also excluded are charges related to error MS-DRGs 0, 998, 999. Individual cases where LOS is greater than the Geographic Mean LOS times 1.5 are excluded. Low volume DRGs where number of cases were < 10 and high dollar outliers are also excluded.
- File Contents. The information provided herein is as required by The Centers for Medicare & Medicaid Services’ Price Transparency Final Rule and is not a guarantee of final billed charges, which may vary from these estimates for many reasons including the individual patient’s unique medical condition, complications, unknown circumstances, other diagnoses and recommended treatments. Moreover, these estimates may not include professional fees such as physician, radiologist, anesthesiologist, and pathologist fees. The insurance benefit information (where applicable) is based on information provided by insurers which may not be current on the date of a scheduled procedure, and benefits and eligibility are subject to change and are not a guarantee of payment:
- CDM Item Number: Unique code used to identify a specific service or supply implicated/rendered in a specific location.
- Revenue Code: Sequence of 4-digit numbers that are used on hospital bills to tell the insurance companies either where the patient was when they received treatment, or what type of item a patient might have received as a patient.
- Service ID: MS-DRG code for inpatient stay and CPT/HCPC billing code for outpatient services
- Service Mod1: Applicable first modifier billed on service line
- Service Mod2: Applicable second modifier billed on service line
- Service Description: – Consumer friendly description of service, item or pharmaceutical
- Minimum Gross Charge – Minimum gross charge for an item or service
- Maximum Gross Charge – Maximum gross charge for an item or service
- Discounted Cash Price – The discounted cash price information is subject to hospital-specific policy guidelines for financial assistance discounting. Patients can determine their eligibility and associated discount by contacting the hospital.
- De-identified min contracted rate – The minimum derived contracted rate across all payors (All payers)
- De-identified max contracted rate - The maximum derived contracted rate across all payors (All payers)
- Payer Negotiated Charge – The negotiated charge with selected payer and plan
Comprehensive, machine-readable files with pricing of all items and services are available to download here:
Adirondack Health pricing
Uninsured Discount Policy
Below, there is a patient liability estimator tool, which displays shoppable services in what we hope you will find to be a consumer-friendly format.
At Adirondack Health, we value your trust and are committed to guiding you and your loved ones on the path to better health. If you have any questions about our pricing information, please email us at pricing@adirondackhealth.org.
