Frequently asked questions

Gundersen is providing a list of standard hospital charges for inpatient and outpatient services as part of the Affordable Care Act (ACA) and policy mandated by the U.S. Department of Health and Human Services and Centers for Medicare and Medicaid (CMS).

Hospital charges, sometimes also called facility charges, can include services, supplies, pharmaceuticals, implants, laboratory tests and imaging. Hospital charges do not include professional fees for services provided by your doctor or other licensed medical professionals. Because many services that are provided at Gundersen sites are divided into and billed in hospital (facility) and professional components, professional fees are provided for additional clarity.

Hospital charge data is not representative of expected out-of-pocket cost. Each patient’s case and benefits are different. The actual amount owed by a patient depends on the individual’s insurance benefits.

There are many reasons that charges may differ among hospitals.

• Payer mix: Government programs (like Medicare and Medicaid) generally reimburse facilities at rates that do not cover the costs they incur to provide care. Therefore, hospitals that have a relatively high percentage of government-program patients are forced to recover a greater percentage of their operational costs from privately insured and self-pay patients through higher charges.
• Facility cost structures: Facilities differ in their approach to pricing based on operational costs. Some facilities try to spread the cost of all services and equipment among all patients. Others establish charges for specific services based on the cost to provide each specific service. Furthermore, some facilities may decide, or be forced, to provide certain services at a loss while other facility operations subsidize the losses. Any of these situations can result in significantly different charges among hospitals for a given type of service.
• New technology: The equipment facilities use to provide services differs in age, sophistication, and frequency of use and may impact the charges of the hospital.
• Staffing costs: Salary scales may differ by region and are typically higher in urban areas. Shortages of nurses and other medical personnel may affect regions differently. Where shortages are more severe, staffing costs, and therefore charges, may be higher.
  Intensity of care: Some facilities are equipped to care for more severely-ill patients than others. Patients within the same diagnosis or procedure category may need very different levels of service and staff attention, causing a variation in charges.
• Range of services provided: Facilities differ in the range of services they provide to patients. Some may provide the full range of services required for diagnosis and treatment during the stay. Others may stabilize patients and then transfer them to another facility for more specialized or rehabilitative care.
• Service frequency: The per-patient cost of services is generally higher if the type of hospitalization occurs infrequently at the facility. Furthermore, a single case with unusually high or low charges can greatly affect a facility’s average charge if the facility reported only a few cases in a given period of time.
• Documentation: Hospitals are required to follow correct coding guidelines and to code all the conditions documented in the patient’s medical record. The hospital bill will reflect charges to the greatest level of specificity as documented in the medical record by clinicians.
• Capital expenses: Facilities differ in the amount of debt and depreciation they must cover in their charge structure. A facility with a lot of debt may have higher charges than a facility not facing such expenses. Furthermore, facilities may choose to lease or purchase equipment or facilities. The choices made about financing of capital projects may affect charges in different ways.

For Wisconsin hospitals, visit WIPricepoint. For Iowa hospitals visit iowahospitalcharges.com.

The best way to determine your out-of-pocket costs is to contact your insurance company. You can find their contact information on your insurance card.

There are several reasons:

• Government programs such as Medicare and Medicaid typically pay healthcare providers much less than the billed charge. These payments are determined solely by the government, and hospitals have no ability to negotiate the reimbursement rates for government-paid services.
• Commercial insurers or other purchasers of healthcare services usually negotiate discounts with healthcare facilities on behalf of the patients they represent.
• Hospitals have policies that allow low-income persons to receive reduced-charge or free care.
• Negotiations between facilities and healthcare purchasers generally begin with the charge amount. While each facility’s charge structure may vary in important ways, charges represent a consistent, though imperfect, way to compare healthcare costs.