Price Estimate

An estimate is the predicted amount you and/or your insurer will have to pay for medical services. The estimate is based on Aspirus’ charges and your insurance plan benefit. While Aspirus attempts to provide accurate estimates, Aspirus cannot guarantee the accuracy of the estimate nor does Aspirus have authority over your insurer’s policies regarding payment for medical services.

Most Hospital services result in both a Facility Fee and a Professional Fee. Your estimate will contain the Facility Fee along with items commonly included in the service such as supplies, and an average amount of contrast materials used in imaging scans.  Your estimate will include the Professional Fee if it is billed by Aspirus. Your estimate will not include a Professional Fee if it is not billed by Aspirus. Please contact your independent healthcare provider for an estimate of the Professional Fee when it is not billed by Aspirus.

In-Network or Participating is when your Aspirus provider is part of your health plan’s preferred network of physicians and healthcare facilities. The amount you pay is usually lower when you receive care from a participating provider. 

Out-of-Network or Non-Participating is when your Aspirus provider is not part of your health plan’s preferred network of physicians and healthcare facilities.  Your health plan may be designed without any preferred network.  Receiving care from an Out-of-Network healthcare provider can mean your insurance plan will not cover some or all the costs of service and you will be responsible for any unpaid balance.

Professional fee is a charge for the services of a healthcare provider such as a Physician, Nurse Practitioner or Physician Assistant.  It is separate and distinct from the Facility Fee.  Imaging tests commonly have Professional Fees since a radiologist reviews the images and provides his/her professional interpretation of the results.  Aspirus will bill you a Professional Fee when your provider is an Aspirus hospital or clinic employee or we have an agreement to manage his/her professional billing.  If your provider is independent with privileges to practice at Aspirus (such as providers from Radiology, ENT, GI or Surgical Associates), the provider will bill you separately for the Professional Fee.  

Facility Fee is a charge for the services of the Hospital or Clinic.  It is separate and distinct from the Professional Fee of the provider (such as a Physician, Nurse Practitioner or Physician Assistant).  Facility Fees represent the charges for the resources involved in providing care to you.  These resources may include the use of the room and associated utilities, nursing or clerical time, the services of non-physician staff members like imaging and lab technicians and supplies or equipment.  Facility Fees are typically itemized and individually charged on bills that you receive, but Facility Fees may be bundled together for the purpose of your estimate.

Coverage Determination is the decision made by your insurer that a medical service is covered under the terms of your policy with them, and what amount you and your insurer will each have to pay for a medical service.  Not all plans pay for the same services in the same way. Aspirus is not responsible for the Coverage Determination made by your insurer.  If your insurer does not pay for any or all of the cost of the medical services you receive, you will remain personally liable for the unpaid balance of those services.  It is your responsibility as the plan member to challenge or appeal a Coverage Determination. 

Deductible is the dollar amount you must pay toward your covered healthcare expenses before your insurance plan begins to pay its share.

Copay (or Copayment) is the fixed dollar amount of your covered healthcare expenses  for which you are responsible. This is usually a flat dollar amount based on a specific type of service.

Coinsurance is the share of your covered healthcare expenses that you are responsible for paying after your deductible is met.  This is usually a percentage of the covered fees.

Out-of-Pocket Maximum is the most you could have to pay on your own for your covered healthcare expenses. This includes your coinsurance and deductible. Afterwards, your insurance plan is expected to pay 100% of the costs of your covered healthcare expenses.

Third-party coverage is when a third-party payer provides benefits and may pay for covered medical expenses for an insurance recipient or designated beneficiary. This includes payment for medical expenses owed to a health care provider or to the insured patient for reimbursement when the insured patient incurs covered out-of-pocket expenses. Third-party payers can be either private or public entities, such as health insurance company or Medicare or Medicaid agency.

Uninsured is a term Aspirus uses to identify patients registered as self-pay and who have no third-party coverage, benefits, or rights of reimbursement relative to the account or charges for services rendered by an Aspirus entity or provider. If a patient chooses to not provide insurance information, bill a third-party coverage, or seek the benefit of a right of reimbursement, the patient shall not meet the definition of Uninsured for purposes of our policy. In addition, deductibles, co-pays, or other balances that are not covered or reimbursed by a payor shall not render the patient Uninsured.

Uninsured Discount Program reduction is the amount Aspirus will reduce a patient’s bill by if the patient is uninsured and does not have third-party coverage.