Price Estimation Tool:

Scotland Health is pleased to offer patients a tool to estimate their out-of-pocket hospital costs for common medical procedures and tests. This online tool calculates the out-of-pocket hospital costs based on the selected procedure and a patient’s insurance information. The tool can also be utilized to estimate hospital costs for patients that do not have insurance coverage. 

We’re committed to helping our patients understand the financial obligations associated with their care. It’s important to understand the tool is not a guarantee of costs and is only an estimate. Please review the disclaimers in detail before using the tool.

We understand that healthcare costs can be very confusing, and we want to ensure patients understand potential costs as clearly as possible. In addition to utilizing our online tool, we encourage patients to contact us at 910-291-7971. Patient Financial Specialists are standing by to educate patients regarding costs and billing.

To access the Price Estimator Tool click here.

List of standard charges:

Scotland Health is committed to empowering patients, in partnership with their care team, to make informed decisions about their healthcare. This includes helping patients understand the cost of their care, as well as financial assistance that may be available.

In compliance with federal regulation, Scotland Health provides a list of standard charges. The public may view the Centers for Medicare and Medicaid Services (CMS) Hospital Pricing Transparency requirements at the following CMS webpage: cms.gov/hospital-price-transparency. The charge lists posted on this website are accurate, with applicable disclaimers, as of the dates indicated within the files. CMS requires hospitals to update annually. Therefore, ongoing additions and changes may not be reflected in the posted files.

The list charge of a hospital service is not equal equivalent to the actual amount paid by governmental or commercial insurance companies; accordingly, each patient’s financial responsibility may vary. The amount a patient pays is based on many factors, including health insurance, benefit plans and other applicable discounts, as well as the services provided based on each patient’s unique needs.

Scotland Health reviews its hospital charges annually to ensure they accurately reflect the high-quality care we seek to provide. In some cases, our charges are different from other providers when we offer a differing level of care or unique clinical expertise. Overall, Scotland Health works with patients, providers and partners to lower the cost of care through wellness programs, disease management and quality care.

Disclaimer:

The comprehensive, machine-readable files below are posted to comply with federal regulations. Due to the nature of the files, they will likely be of limited utility to any specific patient and are not intended for consumer or patient use.

For a patient to best understand their estimated out-of-pocket costs, it’s important to understand their insurance plan benefits and coverage before seeking medical care. Any amount not covered by the plan becomes the financial responsibility of the patient or their guarantor (such as a parent of a minor child).

At the top of this page is a self-service Price Estimation Tool, which can help patients and consumers obtain cost estimates for many common hospital services Scotland Health provides. For more specific cost estimates, patients may call 910-291-7971, Monday through Friday, 8:30 a.m. to 5 p.m. Eastern Time to speak with a Patient Financial Services Representative.

In order to get the most accurate estimate, please consult with your physician to obtain the procedure codes that will be related to your treatment. This information will allow Scotland Health to provide you with a service-specific hospital price estimate based on your individual circumstances and patient responsibility.

Payer and data inquiries should be directed to 910-291-7971.

If you are a member of the media using this tool to research a story, please contact tracie.stubbs@scotlandhealth.org for assistance.

Accessing any files constitutes your agreement that you have read the above content and any additional supplementary disclaimers contained below.

Scotland Health utilizes Epic as its third-party information system for patient billing, which houses its payer contract information. Scotland Health is using Epic’s standard output as the content for most of the facility-specific machine-readable standard charges files.

Due to limitations in presenting complicated and differing contracted rate methodologies in a standardized way, the contracted rate (i.e., payer-specific negotiated charges) in the machine-readable files will not always reflect the contracted rate that applies in an individual patient’s case. As described below, there are variables that exist by patient and/or health insurance plan that must be taken into account to arrive at contracted rates applicable for specific items and services.

If there is a discrepancy between a payer-specific negotiated charge listed in the machine-readable file(s) and the contracted rate applicable to a specific patient claim, the terms of the payer contract will control, so the machine-readable file(s) may be of limited benefit to our patients. We recommend Scotland Health patients use our Price Estimation tool for personalized cost estimates for Scotland Health hospital services.

Examples of potential contracted rate differences include but are not limited to the following:

Payer contracts based on DRG reimbursement

Some payers base rates on diagnosis related group (DRG) reimbursement with additional payment terms. In some cases, a payer-specific negotiated charge provided in the machine-readable file(s) may not always be applicable to an individual case due to differences in negotiated rate methodology that depend on the mix of items and services on a claim. Epic’s calculation methodology reflects rates based on a median patient account for each DRG and may not factor in all applicable contract terms. For example, differences in length of stay and calculation methods may result in a payment rate for some patient claims that vary from the payer-specific negotiated charges reflected in the machine-readable file(s). Furthermore, because of Epic’s logic, the median account chosen to represent the historical gross charge may be a different median account chosen to represent the payer-specific negotiated rate. This may lead to a situation where the negotiated rate looks to be higher than the gross charge when, in reality, the negotiated rate is typically capped at billed charges.

Per diem rates

Per diem rates in the machine-readable file(s) were calculated based on the length of stay for the median account. Rates in an individual case will depend on the patient’s actual length of stay.

Payers with negotiated charges based on age category

Some payers have negotiated charges that are based on age category (for example, adult and pediatric). Epic calculates the contracted rate in the machine-readable file(s) based on a single median account. Rates in the machine-readable file(s) may be calculated based on an adult or a pediatric case.

Medicare Advantage health insurance plans and other payers using Medicare methodology

For Medicare Advantage health insurance plans and payer rates based on Medicare methodology, contracted rates in the machine-readable file(s) may not reflect the rate applicable to every individual case, because Epic’s methodology calculates the contracted rate without factoring in service location, provider group, rate hierarchy and other pricing calculations applicable to Medicare payment methodologies.

Medicare rates are typically updated annually on October 1, for inpatient rate updates, and January 1, for outpatient rate updates. Medicare may make retrospective rate changes that are not reflected in the machine-readable file(s) because the file was created before Scotland Health received notification of the rate change.

Please consult publicly available Medicare rates for additional rate information.

Payers with varying rate terms

Some payer contracts have varying rate methodologies. In some cases, a payer-specific negotiated charge provided in the machine-readable file(s) may not be applicable to an individual case due to differences in negotiated rate methodology that depend on the mix of services on a claim. Differences in service type and location could affect the rates that apply in an individual case.

Multiple procedure reductions

If more than one procedure is performed during a single visit, the contracted rate for the secondary and subsequent procedures could be lower than a single procedure rate, depending on the payer contract terms. The machine-readable file(s) contains the single procedure rate, which may be higher than any applicable multiple procedure rate.

Hierarchy

When a payer contract has multiple negotiated rate methodologies, the contracted rate for some services can take precedence over rates for other services, depending on the mix of services on a claim. The machine-readable file(s) will reflect the contracted rate for a single service, which may be different from the actual rate if multiple services are provided to an individual.

Plan names

Health insurance plan names have trailing numbers in parentheses which are internal Epic indicators but are meaningless to the end-users of the machine-readable file(s) and should be ignored. 

Physician and advanced practice provider professional services

When multiple services are billed during a single visit to a physician or advanced practice provider, contracted rates for the secondary and subsequent services could be reduced, depending on the contract terms/payer policies. Contracted rates in the machine-readable file are for physician services. The contracted rates are based on a single service and do not contain any discounting for multiple services. Contracted rates will also not reflect any discounts from physician rates which may be applicable to services performed by advanced practice providers, such as physician assistants and nurse practitioners.

Out-of-network insured patients

Discounted cash rates are reflective of patients without insurance coverage, and do not apply to patients with health insurance plans for which the hospital is out-of-network.

Prices and contract rates are based on effective date of December 2020.  

The five machine readable files include: Scotland Regional Health Network, Scotland Memorial Professionals, Scotland Memorial Hospital, Scotland Memorial Hospital Self-Pay and Scotland Memorial Min Max.

Scotland Regional Health Network

Scotland Memorial Professionals

Scotland Memorial Hospital

Scotland Memorial Hospital Self-Pay

Scotland Memorial Min Max