When a hospital publishes a price for a colonoscopy or an MRI, it is publishing its facility fee: what the building charges for the room, the equipment, the nurses and the supplies. It is the largest single line on most bills, but it is not the bill. Understanding what sits around it is the difference between a useful comparison and a nasty surprise.
The parts of a hospital bill
A typical outpatient procedure produces three to five separate bills, often from separate companies:
- Facility fee. The hospital's charge for the procedure room or scanner, nursing, supplies, drugs given during the visit, and recovery. This is the number in the hospital's price file and on this site.
- Professional fee. The doctor who performs or interprets the service: the gastroenterologist who does the colonoscopy, the radiologist who reads the MRI, the surgeon. Billed separately, often by a physician group, under the same procedure code with a modifier.
- Anesthesia. Billed by an anesthesiologist or nurse anesthetist, usually by time, and frequently by a company that is not the hospital.
- Pathology and laboratory. Any tissue removed goes to a pathologist, who bills per specimen. Blood tests ordered around the procedure are separate lines.
- Ancillaries. Pre-operative testing, imaging, a specialist consultation, physical therapy afterwards.
For a diagnostic colonoscopy with a facility fee of $1,500, it is common for the physician fee to be $300 to $600, anesthesia $300 to $800 and pathology $100 to $400 per specimen. The facility fee is the largest piece, but the total can be double it.
Why hospitals bill this way
Hospitals and physicians are paid separately under Medicare, and every other payer copied the structure. The hospital is paid for the "technical" component and the doctor for the "professional" one; each has its own fee schedule and its own contract with each insurer. Anesthesia groups and pathology labs are often independent businesses that contract with the hospital for space. The result is that nobody in the building can tell you the whole price, because nobody in the building sets it.
Facility fees in clinics
The same concept appears in doctors' offices that a hospital owns. When a hospital buys a practice, it can start billing a facility fee for office visits that used to have only a professional fee, sometimes doubling the cost of an identical visit in an identical room. Hospital price files list these visit codes (99203 to 99215); an independent practice's price for the same visit is usually lower and has no facility fee. Where you are seen matters as much as who sees you.
How to get the whole picture
Under the No Surprises Act, if you are uninsured or paying yourself, you are entitled to a good faith estimate in writing before a scheduled service, and it must include the expected charges from the other providers involved, not just the hospital. Ask for it by name. Then compare its facility line with the hospital's published cash price; if the estimate is higher, ask why.
If you are insured, ask the hospital for the negotiated rate for your plan for the facility fee, and ask the physician group and anesthesia group whether they are in your network. An in-network hospital with an out-of-network anesthesiologist was the classic surprise bill; the No Surprises Act now limits what you can be charged in that situation, but only if you did not sign a waiver.
What to say
"I would like the self-pay price for CPT 45378, in writing, and whether it includes the physician, anesthesia and pathology. If not, who bills those and what are their self-pay rates?" A hospital that cannot answer that question is telling you something too.