Problem:
Response
Hi everyone, my name is Carly. I was born and raised in San Diego, and I received my BSN from San Diego State University in 2021! I have been working as a registered nurse in the SICU for around four years. In my current role as a bedside nurse, I most commonly care for post op cardiac patients, stroke patients, and abdominal surgery patients. I am currently enrolled in the MSN track for nurse executive leadership. After completing this program, I plan to stay within the ICU. However, I would eventually like to work my way up to a leadership position at my hospital and help to enact positive changes for both patients and staff. Need Assignment Help?
All four of the patient's questions are important because they help the patient understand their personal financial responsibility for their healthcare outside of their insurance coverage. The first question, "How much would the procedure cost because I have not yet met my deductible?" matters because until a patient's deductible is met, patients are responsible for paying the full cost of care. Knowing this upfront allows them to plan and reduces the risk of financial stress that might impact their willingness to proceed with treatment (Young & Kirk, 2020). The second question, "Do I need pre-authorization?" is also important since many insurance companies require prior approval for specific procedures if insurance is going to pay for the procedure. If pre-authorization is not obtained, coverage may be denied, leaving the patient with the entire bill (Centers for Medicare & Medicaid Services, 2021).
The third question, "Is there a facility charge in addition to the physician charge?" is important because patients sometimes are unaware that they can get two separate bills: one from the doctor and one from the hospital or clinic (O'Donnell et al., 2022).. Knowing this ahead of time prevents surprise and frustration when the bill arrives. Lastly, "What other charges would be incurred?" matters because procedures can sometimes come with extra costs, like anesthesia, lab tests, or imaging. Being upfront about these helps patients budget better and avoids confusion later on.
Procedural expenses are determined by several factors, including negotiated reimbursement rates between healthcare organizations and insurance companies, the complexity and length of the procedure, and the resources required such as staff, equipment, and supplies (Caffrey, 2020). Coding systems like CPT (Current Procedural Terminology) and DRGs (Diagnosis-Related Groups) are used to classify and standardize procedures, which directly influence billing and reimbursement amounts. Additionally, geographic location and hospital overhead costs can also impact pricing, leading to variation across facilities. Transparent cost structures are increasingly emphasized to help patients understand their financial responsibilities.
When patients feel that billing is clear, fair, and transparent, they are more likely to pay on time, which keeps revenue flowing and reduces the need for collections. On the other hand, if patients feel confused or blindsided by unexpected charges, they may delay payments, dispute bills, or lose trust in the organization.
Casto, A., & White, S. (2023). Principles of Healthcare Reimbursement and Revenue Cycle Management, Eighth Edition.
Garrett, J. B., Helquist, K. C., Smith, S. D., & Tayler, W. B. (2025). Price Transparency and Patient Engagement: Social Messaging Matters. American Journal of Managed Care, 31(8), 398-403.
How do deductibles work? (n.d.). [Video].