Massachusetts is launching a sweeping plan to hold down health care costs. A new law is partly designed to get patients to help drive down prices by shopping for medical care.
On MDsave, the cost of an MRI ranges from $313 to $3,074. Those on high deductible health plans or without insurance can shop, compare prices and save. Read more about how MDsave works. MRI or Magnetic Resonance Imaging is a medical testing procedure that physicians use to image different parts of the body. (like an MRI or CT scan) Copay amount for each visit or test: $50: Note: You won’t need to pay any copays for X-rays, lab tests, or preventive tests and services like health screenings or immunizations. Inpatient care copay rates (Care that requires you to stay one or more days in a hospital).
So when I had a series of migraines over the summer, I decided this was an opportunity to be an engaged, savvy patient.
First decision: whether to even get the doctor-recommended MRI. It’s a very expensive test, and I thought maybe the headaches would just disappear.
But I followed my doctor’s advice, called Newton-Wellesley Hospital and asked for the price of the test. My doctor didn’t know, I got transferred to radiology, I got transferred to billing. Billing said they would call me back. They didn’t. I couldn’t even get a ballpark estimate.
Now, I have insurance with no deductible, so wherever I went was only going to cost me a $25 copayment. (Apologies to all of you with high-deductible or tiered plans out there.)
When I couldn’t get through to Newton-Wellesley, I tried Mass General, which is what we usually hear is the most expensive and best hospital in the country to go to. They were $5,315. That’s for an uninsured patient. For one MRI.
But they couldn’t tell me what my rate was going to be as an insured patient. They said they didn’t have that information. So I hit another wall with another hospital.
Then I tried an independent lab, called Shields. It’s a chain that specializes in MRIs and other radiology tests. Shields said it would have charged between $2,000 and $3,600 for this test (the higher cost is for an MRI with an injectable dye to show contrast). But that’s not what they would bill my HMO Blue Cross plan for my MRI: $600 for the MRI without the contrast dye, and $1,200 for the MRI with the dye is its negotiated rate with my health plan.
Eventually, I got the test at Newton-Wellesley. I thought the price would be somewhere between Mass General and Shields, and I thought there was some value in following my doctor’s recommendation. When I got the bill from Newton-Wellesley I was stunned. It was for $7,468. Turns out this is the price Newton-Wellesley charges someone who is uninsured. If you include the charge for reading the test, the total is almost $8,000, even higher than Mass General. I thought that since Newton-Wellsley knows I’m a Blue Cross member, they’d send me the Blue Cross rate — what Blue Cross was going to pay for the test. They didn’t.
Newton-Wellesley also didn’t tell me that I’d had two MRIs while lying there in the cave wearing headphones that are supposed to ease the earthquake rumble effects of the test. I found this out months later when I got the “Explanation of Benefits” (EOB) from my insurance company. I still don’t know why the hospital ran two tests. My doctor says he only ordered one. So the $7,468 doesn’t sound as bad if it’s the price of two tests. This is all incredibly confusing and about as far from the transparent process that is supposed to help us “shop” for care as you can get.
Tips For Price-Conscious Consumers
If you want to try to shop around, here are few things you should know, if you don’t already:
1) Insurance companies negotiate different rates with different hospitals. I’ve had a hard time getting doctors or hospitals to give me the negotiated rate, but Blue Cross will tell me, if I’m willing to wait on hold and have the exact code for the exact procedure I need. Which brings me to …
2) Get the code for the test of procedure you need. In some cases there will be several billing codes. For example, my MRI codes were 70551 without the dye, 70552 with the dye. I used those numbers in so many different conversations I don’t think I’ll ever forget them. And in the end, since I had another test I didn’t know about, an MRA, I wasn’t using all the right codes. This process really could drive you crazy.
3) Sometimes your insurance company will send you the EOB that lists the price they actually pay the hospital, but good luck trying to decipher all this paperwork.
4) The physician’s charge is often a separate bill, or rather two bills: what the doc charges and what the insurance company pays. You have to ask a lot of questions
Why the huge disparity between what a hospital charges for an MRI and what a stand-alone clinic such as Shields charges? Newton-Wellesley said that it costs a lot to keep a hospital open 24 hours a day. Hospitals lose a lot of money on some services and make it up other other services. MRIs or other tests are a place that they often make up for money lost on services such as mental health.
And hospitals say they lose money taking care of patients with Medicare — that’s mostly for the elderly — or Medicaid — that’s government insurance mostly for the poor. So private insurance payers like me end up paying more for these tests so that the hospitals can have everything balance in the end.
While Shields lab doesn’t have the overhead of a hospital, Tom Shields, the company’s president, says charging more for an MRI to make up for losing money on other services is just a sign that health care finances are really broken. “You’re reimbursing for diagnostic imaging at a very high rate to justify the underpayment for other lines of health care. It’s sort of like justifying the $500 Ace bandage. The logic isn’t there.”
I wasn’t ever able to find out how much of the charge for an MRI is based on “real” costs – like cost of the machine or the salaries of the technician or doctor.
These real costs vary, but in many cases, not much. We know that hospitals with a strong brand name use that brand to boost their charges. Rick Siegrist, who teaches health care management at the Harvard School of Public Health, says hospitals, much like computer giant Apple, can set their charges as they see fit: “A lot of times, people think they’re just going to look at what their cost is and put a little markup on that and that’s what the charge will be. That’s not the way it’s done, just like it’s not the way it’s done in private industry.”
We have the health care industry telling us to shop around, to be smart consumers, to make wise choices, and yet it’s really difficult to do that, because we don’t understand how hospitals set prices, and it can take hours to find a price. The whole pricing system seems very arbitrary. And we’re left trying to make choices based on incomplete or wrong information.
There may be some hope, according to Dr. Gene Lindsey who runs Atrius, the state’s largest physicians group. He said while it’s a long way way off, “Atrius Health will, in a very, very focused way, begin the work that’s necessary to try to deliver what the bill asks for in terms of cost transparency.”
Atrius and a few other physicians groups have started putting some price information in the record that doctors can see when they are speaking to a patient. It’ll be a tough task to say, “You’re going in for an appendectomy and here’s what it’s going to cost,” because there are so many variables when you go into a hospital for a procedure. But Atrius is shopping for software that will pull all the information, like my health insurance data, together so that they can say, “OK, you’re an HMO patient, here’s what you’ll pay” or, “You have a high deductible, here’s what you’ll pay.”
Two months after I had the tests, I got an Explanation of Benefits from my insurer. Blue Cross paid $1,650 for both. Actually, Blue Cross paid $1,360 for the tests and $290 in physician fees. I never saw a bill for the physician fees, I had to call to get that number. Again, a remarkable lack of transparency.
Then the broader advice is: If you really have to pay attention to price because you have a high-deductible or a tiered coverage plan, then do a lot of deep breathing. Be ready for a long journey that will take some patience.
Oh, and I don’t have a brain tumor or anything serious. My doctor sent me a note. My MRI and MRA showed “white matter with a propensity for migraine.” White matter is just brain tissue, by the way, not little bits of white junk floating around in my brain. I’m fine; I just need to get more sleep.
This story is part of a reporting partnership that includes WBUR, NPR and Kaiser Health News.
This online publication has been updated to include the Amendments through January 1, 2014. For details such as the effective dates of amendments, see your group-specific amendments in the Publications & Forms section of this site.
Here's a guide to your copayments for services covered under The Empire Plan. See your Empire Plan Certificates for details.
Services by Empire Plan Participating Providers
You pay only your copayment when you choose Empire Plan Participating Providers for covered services. Check your directory for Participating Providers in your geographic area, or ask your provider. For Empire Plan Participating Providers in other areas and to check a provider's current status, call The Empire Plan toll-free at 1-877-7-NYSHIP (1-877-769-7447) and choose UnitedHealthcare or use the online Participating Provider Directory.
Office Visit: $20 Copayment
Office Surgery: $20 Copayment
(If there are both an Office Visit charge and an Office Surgery charge by a Participating Provider in a single visit, only one copayment will apply, in addition to any copayment due for Radiology/Laboratory Tests.)
Radiology, Single or Series; Diagnostic Laboratory Tests: $20 Copayment
(If Outpatient Radiology and Outpatient Diagnostic Laboratory Tests are charged by a Participating Provider during a single visit, only one copayment will apply, in addition to any copayment due for Office Visit/Office Surgery.)
Routine Mammography Screening: $20 Copayment
Mri Copay Kaiser
Adult Immunizations: $20 Copayment for Herpes Zoster (Shingles) immunization for enrollees age 55 and over but under age 60. Paid in full benefit for adult immunizations as recommended by the Advisory Committee on Immunization Practices of the Center of Disease Control and Prevention when received from a participating provider.
Allergen Immunotherapy: No Copayment
Well-Child Office Visit, including Routine Pediatric Immunizations: No Copayment
Prenatal Visits and Six-Week Check-Up after Delivery: No Copayment
Chemotherapy, Radiation Therapy, Dialysis: No Copayment
Authorized care at Infertility Center of Excellence: No Copayment
Hospital-based Cardiac Rehabilitation Center: No Copayment
Free-standing Cardiac Rehabilitation Center Visit: $20 Copayment
Urgent Care Center: $20 Copayment
Contraceptive Drugs and Devices when dispensed in a doctor's office: $20 Copayment*
(in addition to any copayment(s) due for Office Visit/Office Surgery and Radiology/Laboratory Tests)
*Copayment waived for preventive services under the federal Patient Protection and Affordable Care Act (PPACA). See NYSHIP Online for details. Diagnostic services require Plan copayment or coinsurance.
Outpatient Surgical Locations (including Anesthesiology and same-day pre-operative testing done at the center): $30 Copayment
Medically appropriate local commercial ambulance transportation: $35 Charge
Chiropractic Treatment or Physical Therapy Services by Managed Physical Network (MPN) Providers
You pay only your copayment when you choose MPN network providers for covered services. To find an MPN network provider, ask the provider directly, or call UnitedHealthcare at 1-877-7-NYSHIP (1-877-769-7447) toll free. Internet: https://www.cs.ny.gov.
Office Visit: $20 Copayment
Radiology; Diagnostic Laboratory Tests: $20 Copayment
(If Radiology and Laboratory Tests are charged by an MPN network provider during a single visit, only one copayment will apply, in addition to any copayment due for Office Visit.)
Hospital Outpatient Department Services
Emergency Care: $70 Copayment
(The hospital outpatient copayment covers use of the facility for Emergency Room Care, including services of the attending emergency room physician and providers who administer or interpret radiological exams, laboratory tests, electrocardiogram and pathology services.)
Surgery: $60 Copayment*
Diagnostic Laboratory Tests: $40 Copayment*
Diagnostic Radiology (including mammography, according to guidelines): $40 Copayment*
Administration of Desferal for Cooley's Anemia: $40 Copayment*
Physical Therapy (following related surgery or hospitalization): $20 Copayment
Chemotherapy, Radiation Therapy, Dialysis: No Copayment
Pre-Admission Testing/Pre-Surgical Testing prior to inpatient admission: No Copayment
*Only one copayment ($60 copayment if surgery is included; $40 is diagnostic outpatient services only) per visit will apply for all covered hospital outpatient services rendered during that visit. The copayment covers the outpatient facility. Provider services may be billed separately. You will not have to pay the facility copayment if you are treated in the outpatient department of a hospital and it becomes necessary for the hospital to admit you, at that time, as an inpatient.
Be sure to follow Benefits Management Program requirements for hospital admissions, skilled nursing facility admission and Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), Computerized Tomography (CT), Positron Emission Tomography (PET) scan or Nuclear Medicine tests.
The Empire Plan Mental Health and Substance Abuse Services by Network Providers When You Are Referred by Beacon Health Options
Call The Empire Plan at 1-877-7-NYSHIP (1-877-769-7447) toll-free before beginning treatment.
Mri Copay Aetna
Visit to Outpatient Substance Abuse Treatment Program: $20 Copayment
Visit to Mental Health Professional: $20 Copayment
Emergency Room Care: $70 Copayment
Psychiatric Second Opinion when Pre-Certified: No Copayment
Mental Health Crisis Intervention (three visits): No Copayment
Inpatient: No Copayment
Empire Plan Prescription Drugs*
Note: Medicare-primary enrollees or dependents should refer to the Empire Plan Medicare Rx Evidence of Coverage for prescription copayment amounts
(Only one copayment applies for up to a 90-day supply.)
Up to a 30-day supply from a network pharmacy or through the Mail Order Pharmacy or the Designated Specialty Pharmacy
$5 Copayment – Level 1 Drugs or most Generic Drugs
$25 Copayment – Level 2, Preferred Drugs or Compound Drugs
$45 Copayment – Level 3 or Non-preferred Drugs**
31 to 90-day supply from a network pharmacy
$10 Copayment –Level 1 Drugs or most Generic Drugs
$50 Copayment –Level 2, Preferred Drugs or Compound Drugs
$90 Copayment – Level 3 or Non-preferred Drugs**
Mri Copayment
31 to 90-day supply through the Mail Order Pharmacy or the Designated Specialty Pharmacy
$5 Copayment –Level 1 Drugs or most Generic Drugs
$50 Copayment –Level 2, Preferred Drugs or Compound Drugs
$90 Copayment – Level 3 or Non-preferred Drugs**
*Note: Oral chemotherapy drugs for the treatment of cancer do not require a copayment. In addition, generic oral contraceptive drugs and devices or brand-name drugs/devices without a generic equivalent (single-source brand-name drugs/devices) do not require a copayment.
**If you choose to purchase a brand-name drug that has a generic equivalent, you will pay the non-preferred drug copayment plus the difference in cost between the brand-name drug and its generic equivalent (with some exceptions), not to exceed the full retail cost of the covered drug.
Mri Copay Assistance Programs
***Covered services defined as preventive under the Patient Protection and Affordable Care Act are not subject to copayment.