What's the exact process for calculating cost?
The cost data on this site comes from the State of Maine's All-Payer Claims Database (APCD). We reviewed over 13 million claims from 32 health insurance plans that covered health procedures provided in Maine from January 1, 2017 to December 31, 2017. Note: Surgical procedure cost estimates have not been updated for this release, and their costs remain reflective of the July 1, 2016 through June 30, 2017 time period due to a transition to a new episode grouping tool. CompareMaine does not include information on the uninsured. However, effective January 1, 2014, a provision in the Affordable Care Act addresses what some hospitals may charge individuals eligible for financial assistance for emergency and medically necessary care. We encourage you to explore this law further: Section 501(r)(5).
At this time, these analyses do not include people with Medicare or Medicaid (MaineCare). After these claims were excluded, a total of 6,209,576 claims from 31 payers were analyzed.
The cost estimates on CompareMaine are median payments. They are meant to serve as a reference point for comparison. MHDO makes every effort to provide accurate information on this website. Healthcare providers and insurance companies included on CompareMaine are sent the cost data to review for accuracy before they are released. Estimates published on this website are within 10% of payer and facility estimates.
Please contact your insurance company to find out your actual payment. If you do not have insurance, please contact the facility that you are interested in. When contacted directly, facilities often report their charges which may be higher than the actual payments they receive from insurance companies and patients.
The Steps We Take to Find Procedure Costs
Step 1: Filter the Data
First, we filter the data by taking out entries with missing or unclear information. At this time, we also remove claims from public payers like Medicare and Medicaid and for those 65 years old or older, as these are often paid for in-part by a public payer like Medicare. Including these claims would distort the average. However, this site is still a useful tool for people ages 65 and older with commercial insurance. To protect patient privacy, we do not report a facility's ratings for a specific procedure if the facility has fewer than 5 claims for that procedure in the database:
Incomplete Encounters: Some procedures require professional and facility services. We remove patient encounters that only include either the facility or professional portion.
Encounters Without Cost Data: We remove claims that do not have cost information.
Step 2: Find Claims Linked to a Test or Service
The second step is to find the claims linked to a test or service. CompareMaine shows the average cost for a given medical test or service based on insurance claims that insurance companies are required to submit to the MHDO.
Depending on the procedure, the total cost can include:
Professional Costs: The portion of the cost paid to the healthcare provider, such as nurse, doctor or therapist, who provides direct services or procedures to a patient.
Facility Costs: The portion of the cost paid to the organization that provides healthcare services and procedures. This includes hospitals, surgical centers, diagnostic imaging centers, health centers, laboratories and clinics.
Please visit All Cost Procedures to see which costs are included in each procedure.
Step 3: Calculate the Average Cost
The third step is to compute the average cost for each test or service at each facility.
We use the median value rather than the mean to come up with the average cost. A median is the middle value when all items in a sample are sorted from lowest to highest. The mean is figured by adding up all the values and dividing by the number of items in the sample. The problem with using the mean is that it is affected by extreme values that are very high or very low compared to the rest of the sample. We believe the median is better than the mean for summarizing averages in healthcare because it represents the amount that a procedure is most likely to cost. It is less likely to be influenced by extreme values.
Example: Calculating Costs for Blood Tests at Two Facilities
In this example, the costs are the same at the two labs for the first four patients' blood tests. But, Patient E's blood test costs $200 more at Lab 2 than at Lab 1. The median or middle value stayed the same at the two labs. But the mean cost for blood testing is $40 more at Lab 2 (bumped up by the more expensive testing for one patient, Patient E). The median cost, $100, is a better example of what blood testing costs.
|Patient||Lab 1 Costs||Lab 2 Costs|
|Patient A's Blood Test||$50||$50|
|Patient B's Blood Test||$50||$50|
|Patient C's Blood Test||$100||$100|
|Patient D's Blood Test||$100||$100|
|Patient E's Blood Test||$150||$350|
|Total Sum of Blood Testing||$450||$650|
|MEDIAN Cost (middle value in list, Patient C)||$100||$100|
|MEAN (Total Sum/Total Number of Tests)||$90||$130|
Some services like physical therapy (PT) or occupational therapy (OT) are measured in time increments, referred to as "units". These units typically represent 15 minutes of therapy. You may receive multiple units of different types of therapy during one appointment. For example, you may receive 30 minutes (two units) of therapeutic exercise and 15 minutes (1 unit) of ultrasound therapy. So, to estimate your cost for the entire visit, you would multiply the cost of therapeutic exercise by 2 units and the cost of ultrasound therapy by 1 unit and then add the two costs together. In the spring of 2016, we updated our reporting of PT and OT services to calculate the unit cost (for example, 15 minutes of exercise). You may receive multiple units during an appointment.
Patients often receive multiple types of treatment in a physical or occupational therapy appointment and the type of service provided may change over the course of treatment. If you have more than one therapeutic service during the same visit, you will need to look up each service separately. Your PT or OT provider can provide information about what services, including the number of units of each service, will likely be billed during your course of treatment.
When you use CompareMaine, you can filter it by a specific insurance company. If you don't choose an insurance company, the cost shown is the median cost for the test or service at the facility across all insurance companies.
Step 4: Link a Cost to a Facility
Finally, we determine which facility the cost should be assigned to. Sometimes only one facility provides a service, like an office visit with a primary care physician. But procedures may involve more than one facility. For example, if a patient has blood work done, a lab might draw the blood and another lab might test and report the results. When more than one facility provides care, the facility with the largest part of the bill is the "Lead Provider." All the separate costs are linked to the Lead Provider.