In 2017, Amino launched imaging cost estimates for facilities—these are estimates for imaging procedures where the cost is attributed to the facility rather than the individual doctor. You can search by region and calculate what you might pay out-of-pocket for a procedure at a facility based on your insurance. Our cost estimates can help you prepare for the financial impact of medical care and help you make more confident decisions about which facility to choose for treatment.
Amino’s imaging cost estimates for facilities are estimates of the total amount that you and your health insurance company might pay for a procedure—this is what we call the “network rate.” You’ll see the network rate across Amino’s facility profiles. The network rate will vary based on whether or not you’ve specified your insurance.
The network rate is based on Amino’s analysis and data modeling of de-identified data from millions of health insurance claims from over 120 different health insurers—including the largest insurers in the United States like UnitedHealth Group, Aetna, Humana, Cigna, Blue Cross, Blue Shield, and more. The data comes from insurance claims dating between Jan 2012 till today, which means we are able to show cost estimates for millions of combinations of medical procedures, facilities, insurance companies, and regions.
The analysis behind our imaging cost estimates for facilities
Our imaging cost estimates are built around an “episode of care”—a set of related services that a patient may need as they get treated.
For example, in the case of magnetic resonance imaging (MRI), a patient may receive an injection of contrast medium (a substance that improves the visibility of internal organs during radiology), as well as the MRI procedure itself, as part of their episode of care. Patient experience can vary in terms of the services included for the same procedure.
Depending on the place where a service is rendered—for example, inpatient facility, a hospital outpatient department, physician clinic, urgent care center, or other place of service—there may be a corresponding revenue center code in the episode describing where the service was rendered. The costs of these related services sometimes vary from facility to facility and are reflected in the cost estimates you see on Amino’s facility profile pages.
We have built an algorithm that runs on a graphical model of longitudinal insurance claims data to determine the most commonly observed episodes of care for each procedure. These most common episodes are called “canonical episodes.”
Going back to the example of an MRI cost estimate, here’s how the algorithm works: our algorithm starts with the MRI service code, which is a trigger code unique to the procedure. Then the algorithm determines the surrounding codes and modifiers for the MRI to create a set of related services that help define a canonical episode for an MRI. The algorithm computes multiple canonical episodes, and the probabilities of these canonical episodes occurring.
When you’re looking at an imaging cost estimate on an Amino facility profile, you will find the cost for the top canonical episode (aka, the highest probability episode).
Our cost model calculates imaging cost estimates for individual services specific to each insurance plan accepted by a facility. The total cost of the highest probability canonical episode is calculated by summing up the costs for individual services. Additionally, the cost for each individual service that’s included in an episode is also displayed on Amino as part of the aggregate cost estimate amount.
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Imaging cost estimates on Amino’s facility profiles
We currently show imaging cost estimates for more than 35,000 facilities: essentially all facilities in our database that perform the procedures for which we have cost estimates. If you have selected your insurance during your search for a procedure conducted at a facility, you will see the network rate that we’ve determined for the facility specific to that insurance company.
If you have not specified your insurance during your search for a facility on Amino, you will see a range instead of a single cost estimate. For example, let’s say you’re looking for a MRI in San Francisco. To determine the range of cost estimates we’d show, we look in our database to evaluate all of the patients with private insurance who got an MRI in the San Francisco area at all the different facilities. Then, we estimate what these patients would have been charged for a typical MRI, based on the type of insurance they have and the facility they went to. Over these patients, the minimum and maximum costs become the low and high cost estimates for the range we show.
Using the coverage calculator for imaging costs
The coverage calculator helps you understand what you might pay for a procedure, based on your insurance plan. If you select “Calculate What You’ll Pay” while researching cost for a specific procedure or service on Amino, you will see the calculator.
If your Amino account is sponsored by your employer, you will see your medical plan design and current deductible remaining reflected by default when you open the coverage calculator.
The right-hand side of the calculator shows how the three key elements of your plan design—remaining deductible, co-pay, and co-insurance—factor into your out-of-pocket cost estimate.
If you are using a free Amino account, start by choosing a typical insurance plan design or enter your custom plan details. Within the calculator we provide two preset typical insurance plan designs you can choose from: high deductible and low deductible. Many insurance companies have plan options that correspond to these, with Platinum usually having the lowest deductible and lowest co-insurance percentage, and Bronze having the highest deductible and highest co-insurance percentage. You can also enter in your specific plan details if you know them.
Final thoughts and our limitations
Wherever possible, our team conducted checks and validations of our cost estimates by reviewing external research and, in some cases, calling up facilities, reviewing “Explanations of Benefits” from real patients, and working closely with medical coding experts.
Our imaging cost estimates are designed to help you make more informed healthcare decisions, but they are not a prediction of the price you’ll find on your next bill from a medical facility. The data we use to power our estimates are a snapshot of the dollar amounts health insurance companies have paid for select procedures and services in the recent past. They are not guaranteed prices that health insurance companies will continue to pay in the future. If a health insurance company and a facility negotiate a new rate for a procedure that is different from what we’ve seen in the past, the change will not be immediately reflected in our cost estimates.
Additionally, we do not have a complete picture of every payment health insurance companies have made to every facility in America. As a result, for some facilities, we do not have enough data for certain procedures. In these cases, we create cost estimates by computing the median cost paid to the facilities in the same city or state, or some other appropriate level of aggregation. These reference costs allow us to fill gaps in our data.
The facility that you go to and the doctors that practice there might recommend testing and treatment during your episode of care that is different from the episode of care we use to produce our cost estimates, which could make your total cost significantly different from our cost estimate. Therefore, Amino cannot guarantee the price you’ll be charged by a doctor or hospital. We also don’t have cost estimates for uninsured individuals or those paying in cash, since many facilities do not (or cannot) make these cost estimates public or easily accessible. Amino recognizes the importance of these cash prices and will be looking into new data sources in the future to serve this need.
Our estimates are based on an analysis of what most patients typically experience, which can provide helpful context as you plan for care. For more specific estimates based on your particular health needs, we recommend that you call your health insurance company’s customer support line or the specific facility you are planning on going to for your care to confirm what is covered and what you might pay.
Due to the nature of our insurance claims data and available resources, it is challenging to accurately and fairly take into account the complexities of individual patients’ case variation or understand every facility’s complete patient mix. Therefore, we are currently not conducting risk adjustment for our cost estimates. We understand the importance of risk adjustment, and we will strive to incorporate risk adjustment into our analyses in a future version of our product.
For more information about our methodology, contact us at firstname.lastname@example.org.