Frequently Asked Questions
What is the difference between a submitted charge and a Medicare payment?
The submitted charge (also called the 'list price' or 'chargemaster rate') is the amount a provider bills for a service before any negotiated discounts. The Medicare payment is what Medicare actually reimburses — always less than the submitted charge. For most procedures, Medicare pays 20-40% of the submitted charge. Private insurers negotiate their own rates, typically somewhere between the two.
Why are submitted charges so much higher than what Medicare pays?
Hospital and provider list prices (chargemaster rates) are set high to allow negotiation flexibility with insurers, who each negotiate different discount rates. In practice, no payer — Medicare, Medicaid, or commercial insurance — pays list price. The list price only matters to uninsured patients or those receiving out-of-network care without financial assistance.
Can I use this data to know what my procedure will actually cost?
Medicare payment data is a useful reference but not a quote. Your actual cost depends on your insurance plan, deductible status, whether your provider is in-network, and your specific medical circumstances. The Medicare payment shown is what Medicare pays the provider — your share (20% coinsurance after deductible) is separate.
What is a CPT code?
Current Procedural Terminology (CPT) codes are standardized codes maintained by the American Medical Association that describe medical, surgical, and diagnostic services. Every service billed to insurance uses a CPT or HCPCS code to identify exactly what was provided. PlainProcedure organizes all 9,297 procedures in the CMS dataset by CPT/HCPCS code.
Why do procedure costs vary so much by state?
Medicare adjusts payments by geographic area using Geographic Practice Cost Indices (GPCIs) reflecting local costs of physician work, practice expenses, and malpractice insurance. High-cost areas like California, New York, and urban Massachusetts receive higher Medicare payments than rural areas. These same adjustments apply to commercial insurance rates in most markets.
Does PlainProcedure cover hospital costs for inpatient stays?
PlainProcedure focuses on Medicare Part B physician and outpatient procedure data. Inpatient hospital costs (Medicare Part A, DRG payments) are a separate CMS dataset and are not currently included in PlainProcedure.
Is PlainProcedure affiliated with CMS or Medicare?
No. PlainProcedure is an independent data portal and is not affiliated with the Centers for Medicare & Medicaid Services, Medicare, or any government agency. We present publicly available CMS data to help patients, researchers, and journalists understand healthcare pricing.