Patient Price Information List

Disclaimer: Northeast Montana Health Services - Poplar Hospital determines its standard charges for patient items and services through the use of a chargemaster system, which is a list of charges for the components of patient care that go into every patient’s bill. These are the baseline rates for items and services provided at the Hospital. The chargemaster is similar in concept to the manufacturer’s suggested retail price (“MSRP”) on a particular product or good. The charges listed provide only a general starting point in determining the potential costs of an individual patient’s care at the Hospital. This list does not reflect the actual out-of-pocket costs that may be paid by a patient for any particular service, it is not binding, and the actual charges for items and services may vary.

Many factors may influence the actual cost of an item or service, including insurance coverage, rates negotiated with payors, and so on. Government payors, such as Medicare and Medicaid for example, do not pay the chargemaster rates, but rather have their own set rates that hospitals are obligated to accept. Commercial insurance payments are based on contract negotiations with payors and may or may not reflect the standard charges. The cost of treatment also may be impacted by variables involved in a patient’s actual care, such as specific equipment or supplies required, the length of time spent in surgery or recovery, additional tests, or any changes in care or unexpected conditions or complications that arise. Moreover, the foregoing list of charges for services only includes charges from the Hospital. It does not reflect the charges for physicians, such as the surgeon, anesthesiologist, radiologist, pathologist, or other physician specialists or providers who may be involved in providing particular services to a patient. These charges are billed separately.

Individuals with questions about their out-of-pocket costs of service and other financial information should contact the hospital or consider contacting their insurers for further information.

LOCAL MARKET HOSPITALS

In order to present a meaningful comparison, Northeast Montana Health Services - Poplar Hospital has partnered with Hospital Pricing Specialists LLC to analyze current charges, based off CMS adjudicated claims through 3/31/18. Northeast Montana Health Services - Poplar Hospital's charges are displayed and compared with the local market charge, consisting of the following hospitals:

Hospital Name
Location

Dahl Memorial Healthcare Association

Ekalaka

MT

Daniels Memorial Healthcare Center

Scobey

MT

Fallon Medical Complex

Baker

MT

Frances Mahon Deaconess Hospital

Glasgow

MT

Garfield County Health Center

Jordan

MT

Glendive Medical Center

Glendive

MT

McCone County Health Center

Circle

MT

Northeast Montana Healthcare Trinity Hospital

Wolf Point

MT

Phillips County Hospital

Malta

MT

Prairie Community Health Center

Terry

MT

Roosevelt Medical Center

Culbertson

MT

Sheridan Memorial Hospital

Plentywood

MT

Sidney Health Center

Sidney

MT

INPATIENT ROOM AND BOARD DAILY CHARGES

Description

Our Charge
Market Charge

Variance

Private Room

$880
$1,806

51% lower than market

Semi-Private Room

$880
$1,802

51% lower than market

OUTPATIENT EMERGENCY DEPARTMENT CHARGES

Emergency Department charges are based on the level of emergency care provided to our patients. The levels, with Level 1 representing basic emergency care, reflect the type of accommodations needed, the personnel resources, the intensity of care and the amount of time needed to provide treatment. The following charges do not include fees for drugs, supplies or additional ancillary procedures that may be required for a particular emergency treatment. They also do not include fees for Emergency Department physicians, who will bill separately for their services.

Description

Our Charge
Market Charge

Variance

Emergency Critical Care; Each Additional 30 Minutes

$686
$361

90% higher than market

Emergency Critical Care; First 30 Minutes

$2,877
$1,448

99% higher than market

Emergency Department Visit - Level 1

$209
$204

2% higher than market

Emergency Department Visit - Level 2

$460
$296

55% higher than market

Emergency Department Visit - Level 3

$560
$423

32% higher than market

Emergency Department Visit - Level 4

$797
$576

38% higher than market

Emergency Department Visit - Level 5

$1,177
$1,039

13% higher than market

OUTPATIENT PULMONARY THERAPY CHARGES

The following charges reflect the most common services offered by our Pulmonary Therapy department. Patients may have additional charges, depending on the services performed.

Description

Our Charge
Market Charge

Variance

Routine EKG - Minimum 12 Leads

$118
$189

38% lower than market

OUTPATIENT LABORATORY AND PATHOLOGY CHARGES

The following charges reflect our most common laboratory procedures. For all lab specimens collected via blood draw, the venipuncture will be charged separately.

Description

Our Charge
Market Charge

Variance

Albumin Level

$28
$50

44% lower than market

Ammonia Level

$122
$114

7% higher than market

Amylase

$94
$124

24% lower than market

Analysis for antibody to Cytomegalovirus (CMV)

$144
$180

20% lower than market

Antibody Screen

$436
$293

49% higher than market

Arterial Blood Gases Measurement

$216
$294

26% lower than market

Bacterial Blood Culture

$130
$210

38% lower than market

Bacterial Culture for Aerobic Isolates

$123
$72

70% higher than market

Bacterial urine culture; quantitative colony count

$119
$131

9% lower than market

Basic Metabolic Panel

$152
$131

16% higher than market

Bilirubin Level; Direct

$65
$58

12% higher than market

Blood Creatinine

$65
$51

26% higher than market

Blood Glucose Level Test

$50
$76

34% lower than market

Blood Potassium Level

$65
$65

Approximately equal to market

Blood Typing; ABO

$55
$73

25% lower than market

Blood Typing; Rh (D)

$9
$53

83% lower than market

Blood Unit Compatibility Test; Immediate Spin Technique

$253
$168

50% higher than market

Blood typing for red blood cell antigens

$62
$58

8% higher than market

Breath test analysis for helicobacter pylori

$273
$218

25% higher than market

Calcium Level

$74
$59

24% higher than market

Coagulation Function Measurement; D-dimer; quantitative

$124
$133

6% lower than market

Complete Blood Count

$92
$74

24% higher than market

Complete Blood Count/Differential

$101
$82

23% higher than market

Comprehensive Metabolic Panel

$229
$185

24% higher than market

Creatine Kinase

$95
$83

14% higher than market

Creatine Kinase Level

$163
$123

32% higher than market

Creatinine Level to Test for Kidney Function

$66
$60

9% higher than market

Detection Test for Hepatitis C Virus; Includes Reverse Transcription

$282
$614

54% lower than market

Detection test for HIV-1 and HIV-2

$131
$121

8% higher than market

Detection test for multiple types influenza virus

$251
$179

40% higher than market

Digoxin Level

$123
$147

17% lower than market

Drug Test(s) by Chemistry Analyzer

$110
$151

27% lower than market

Drug test(s) presumptive; any number of drug classes; includes sample validation when performed

$230
$159

45% higher than market

Hemoglobin A1c

$148
$128

15% higher than market

Hemoglobin Measurement

$35
$44

20% lower than market

Hepatitis C Antibody Measurement

$154
$126

22% higher than market

Immunologic analysis for detection of organism; qualitative or semiquantitative; multiple-step method

$216
$92

134% higher than market

Ionized Calcium

$127
$132

4% lower than market

Ketone bodies analysis; quantitative

$43
$50

14% lower than market

Kidney Function Blood Test Panel

$122
$137

11% lower than market

Lactic Acid

$191
$139

37% higher than market

Lipase

$108
$97

10% higher than market

Lipid Panel

$141
$154

9% lower than market

Liver Panel

$115
$167

31% lower than market

Magnesium Level

$73
$81

10% lower than market

Measurement C-reactive protein

$68
$72

6% lower than market

Measurement high sensitivity C-reactive protein

$97
$93

4% higher than market

Microscopic Examination of White Blood Cells with Manual Count

$44
$51

13% lower than market

Myoglobin (muscle protein) level

$167
$95

76% higher than market

Natriuretic Peptide

$286
$234

22% higher than market

PSA Measurement; Total

$184
$149

23% higher than market

Partial Thromblostatin Time; Activated

$147
$138

6% higher than market

Phosphate Level

$65
$66

1% lower than market

Prothrombin Time

$88
$56

56% higher than market

Qualitative or semiquantitative detection test for helicobacter pylori in stool; multiple-step metho

$78
$217

64% lower than market

Red Blood Cell Concentration Measurement

$36
$44

19% lower than market

Red Blood Cells; Leukocytes Reduced; Each Unit

$649
$542

20% higher than market

Antihuman globulin test (Coombs test); direct; each antiserum

$78
$74

5% higher than market

Red blood cell sedimentation rate; to detect inflammation; non-automated

$47
$58

19% lower than market

Screening Test for Red Blood Cell Antibodies

$105
$117

11% lower than market

Streptoccus

$110
$96

14% higher than market

Thyroid Hormone; T3 Measurement; Free

$214
$187

14% higher than market

Thyroid Stimulating Hormone (TSH)

$167
$101

66% higher than market

Thyroxine

$118
$106

11% higher than market

Troponin

$132
$113

17% higher than market

Urea Nitrogren

$54
$54

1% lower than market

Uric Acid Level; Blood

$69
$63

8% higher than market

Urinalysis with Examination; using Microscope

$52
$57

9% lower than market

Urinalysis with Microscopy

$31
$32

2% lower than market

Urinalysis; Automated Test

$33
$41

20% lower than market

Urine Pregnancy Test

$58
$70

17% lower than market

Urine microalbumin (protein) analysis

$118
$83

43% higher than market

Vancomycin Level

$176
$180

3% lower than market

Vitamin D-3 Level

$268
$203

32% higher than market

OUTPATIENT MEDICINE CHARGES

Description

Our Charge
Market Charge

Variance

Hydration Infusion into a Vein

$141
$90

57% higher than market

Hydration Infusion into a Vein - 31 Minutes to 1 Hour

$388
$254

52% higher than market

Infusion into a Vein for Therapy; Diagnosis; or Prevention

$176
$123

42% higher than market

Infusion of Drug or Substance into Vein for Therapy or Diagnosis

$388
$319

21% higher than market

Injection Beneath the Skin for Therapy; Diagnosis; or Prevention

$115
$79

44% higher than market

Sleep Monitoring with CPAP

$3,349
$3,072

9% higher than market

Sleep monitoring of patient (6 years or older) in sleep lab

$3,030
$2,785

9% higher than market

OUTPATIENT OTHER CHARGES

Description

Our Charge
Market Charge

Variance

Hospital Observation per Hour

$87
$139

38% lower than market

Non-covered item or service

$39
$9

343% higher than market

OUTPATIENT PHARMACY AND DRUG ADMINISTRATION CHARGES

Description

Our Charge
Market Charge

Variance

Injection of Drug or Substance into Vein for Therapy or Diagnosis

$388
$170

128% higher than market

Injection of New Drug into Vein for Therapy or Diagnosis

$162
$113

43% higher than market

5% dextrose/water (500 ml = 1 unit)

$4
$36

90% lower than market

Infusion; normal saline solution ; 1000 cc

$45
$47

4% lower than market

Infusion; normal saline solution; 250 cc

$4
$45

92% lower than market

Infusion; normal saline solution; sterile (500 ml = 1 unit)

$14
$60

76% lower than market

Injection; Azithromycin; 500 mg

$27
$25

9% higher than market

Injection; Ceftriaxone Sodium; per 250 mg

$18
$8

130% higher than market

Injection; Enoxaparin Sodium; 10 mg

$27
$12

126% higher than market

Injection; Furosemide; up to 20 mg

$18
$39

54% lower than market

Injection; Hydromorphone; Up to 4 mg

$40
$41

2% lower than market

Injection; Ketorolac Tromethamine; per 15 mg

$10
$17

38% lower than market

Injection; Levofloxacin; 250 mg

$20
$20

1% higher than market

Injection; Lorazepam; 2 mg

$20
$30

34% lower than market

Injection; Methylprednisolone Sodium Succinate; up to 125 mg

$35
$47

26% lower than market

Injection; Morphine Sulfate; up to 10 mg

$20
$34

41% lower than market

Injection; Ondansetron Hydrochloride; per 1 mg

$18
$8

127% higher than market

Injection; Vancomycin HCL; 500 mg

$27
$24

14% higher than market

Injection; acetaminophen; 10 mg

$1
$2

15% lower than market

Injection; insulin; per 5 units

$7
$6

17% higher than market

Ringers lactate infusion; up to 1000 cc

$12
$46

74% lower than market

OUTPATIENT RESPIRATORY THERAPY CHARGES

The following charges reflect the most common services offered by our Respiratory Therapy department. Patients may have additional charges, depending on the services performed.

Description

Our Charge
Market Charge

Variance

Arterial Puncture

$212
$153

38% higher than market

Nebulizer Treatment

$119
$99

19% higher than market

OUTPATIENT SURGICAL SERVICES CHARGES

Description

Our Charge
Market Charge

Variance

Insertion of Breathing Tube Using an Endoscope

$175
$261

33% lower than market

Insertion of Indwelling Bladder Catheter

$62
$205

70% lower than market

Insertion of Needle into Vein to Collect Blood

$31
$23

31% higher than market

Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older

$1,478
$1,368

8% higher than market

Transfusion of Blood or Blood Products

$160
$697

77% lower than market

Simple wound repair of scalp; neck; external genitalia; 2.5 cm or less

$146
$287

49% lower than market

OUTPATIENT TRANSPORTATION CHARGES

Description

Our Charge
Market Charge

Variance

Ground mileage; per statute mile

$24
$21

13% higher than market

OUTPATIENT X-RAY AND RADIOLOGICAL CHARGES

The following charges reflect our most common x-ray and radiological procedures. For all exams requiring contrast, the contrast will be charged separately.

Description

Our Charge
Market Charge

Variance

3D radiographic procedure

$505
$422

20% higher than market

CT Abdomen & Pelvis with Contrast

$1,791
$2,510

29% lower than market

CT Abdomen & Pelvis with and without Contrast

$2,273
$3,225

35% lower than market

CT Abdomen & Pelvis without Contrast

$901
$1,282

35% lower than market

CT Angiogram Abdomen & Pelvis with and without Contrast

$3,035
$2,293

32% higher than market

CT Angiogram Chest with and without Contrast

$2,691
$2,683

Approximately equal to market

CT Angiogram Neck with and without Contrast

$2,650
$2,777

5% lower than market

CT Chest with Contrast

$1,724
$1,784

3% lower than market

CT Chest without Contrast

$1,540
$1,462

5% higher than market

CT Face with Contrast

$1,496
$1,385

8% higher than market

CT Face without Contrast

$1,301
$1,158

12% higher than market

CT Head Brain with Contrast

$1,484
$1,510

2% lower than market

CT Head Brain with and without Contrast

$1,892
$1,972

4% lower than market

CT Head Brain without Contrast

$1,148
$1,302

12% lower than market

CT Leg with Contrast

$1,376
$1,434

4% lower than market

CT Leg without Contrast

$1,215
$1,346

10% lower than market

CT Neck with Contrast

$1,584
$1,536

3% higher than market

CT Neck without Contrast

$1,397
$1,331

5% higher than market

CT Pelvis with Contrast

$1,616
$1,513

7% higher than market

CT Pelvis without Contrast

$1,391
$1,307

6% higher than market

CT Scan of Abdominal Aorta and Both Leg Arteries with Contrast

$3,410
$2,503

36% higher than market

CT Spine Cervical without Contrast

$1,482
$1,530

3% lower than market

CT Spine Lumbar without Contrast

$1,471
$1,348

9% higher than market

CT Spine Thoracic without Contrast

$1,567
$1,418

10% higher than market

Chest X-Ray; 2 Views

$290
$268

8% higher than market

Chest X-Ray; Single View

$194
$246

21% lower than market

Imaging of Abdomen; 2 Views

$248
$373

33% lower than market

Imaging of Abdomen; Single View

$194
$233

17% lower than market

X-Ray Ankle; 3 Views

$234
$272

14% lower than market

X-Ray Femus; 2 Views

$194
$244

21% lower than market

X-Ray Foot; 2 Views

$194
$238

19% lower than market

X-Ray Foot; 3 Views

$223
$284

21% lower than market

X-Ray Hand; 3 Views

$259
$314

17% lower than market

X-Ray Hip and Pelvis; 2 Views

$194
$252

23% lower than market

X-Ray Knee; 1-2 Views

$194
$225

14% lower than market

X-Ray Knee; 3 Views

$267
$305

13% lower than market

X-Ray Knee; 4 or More Views

$365
$351

4% higher than market

X-Ray Lower Leg; 2 Views

$194
$235

17% lower than market

X-Ray Lower Sacral Spine; 4 or More Views

$309
$455

32% lower than market

X-Ray Pelvis; 1-2 Views

$304
$220

39% higher than market

X-Ray Ribs One Side; 2 Views

$194
$245

21% lower than market

X-Ray Shoulder; 2 Views

$199
$287

31% lower than market

X-Ray Toes; 2 Views

$194
$226

14% lower than market

X-Ray Upper Spine; 4-5 Views

$304
$381

20% lower than market

X-ray Ribs One Side; Minimum 3 Views

$305
$325

6% lower than market

INPATIENT ORTHOPEDICS CHARGES

Description

Our Charge
Market Charge

Variance

Aftercare; musculoskeletal system & connective tissue without complications

$5,962
$4,212

42% higher than market

Signs & symptoms of musculoskeletal system & connective tissue without major complications

$7,102
$6,588

8% higher than market

BILLING PROCESS AND INFORMATION

How You Can Help

Thank you for choosing Northeast Montana Health Services - Poplar Hospital for your healthcare needs. At Northeast Montana Health Services - Poplar Hospital, we are committed to making the billing process as patient-friendly as possible. Here are some ways you can help the billing process go smoothly.

• Please give us complete health insurance information.

In addition to your health insurance card, we may ask for a photo ID. If you have been seen at Northeast Montana Health Services - Poplar Hospital, let us know if your personal information or insurance information has changed since your last visit.

• Please understand and follow the requirements of your health plan.

Be sure to know your benefits, obtain proper authorization for services and submit referral claim forms if necessary. Many insurance plans require patients to pay a co-payment or deductible amount. You are responsible for paying co-payments required by your insurance provider and Northeast Montana Health Services - Poplar Hospital is responsible for collecting co-payments. Please come to your appointment prepared to make your co-payment.

• Please respond promptly to any requests from your insurance provider.

You may receive multiple bills for your hospital visit, including your family doctor, specialists, physicians to read x-rays, give anesthesia, or do blood work. Insurance benefits are the result of your contract with your insurance company. We are a third-party to those benefits and may need your help with your insurance. If your insurance plan does not pay the bill within 90 days after billing, or your claim is denied, you will receive a statement from Northeast Montana Health Services - Poplar Hospital indicating the bill is now your responsibility. All bills sent to you are due upon receipt.

Questions about Price and Billing Information

Our goal is for each of our patients and their families to have the best healthcare experience possible. Part of our commitment is to provide you with information that helps you make well informed decisions about your own care.

To ask questions or get more information about a bill for services you've received, please contact our Customer Call Center at (406) 768-6100.

If you need more information about the price of a future service, please contact our Price Hotline at (406) 768-6100. A CPT code is strongly encouraged when you call. You can obtain the CPT code from the ordering physician.

Online Payment, Registration, & Scheduling

For the convenience of our patients, a number of online services are available at http://www.nemhs.net/. Northeast Montana Health Services - Poplar Hospital offers secure online payment.

Northeast Montana Health Services - Poplar Hospital also offers pre-registration and appointment requests through a secure online form at http://www.nemhs.net/. Patients may pre-register for surgeries, admissions, outpatient procedures and tests at least three business days in advance. Patients may also pre-register for maternity services up to three months prior to their expected delivery date.

Financial Assistance

We are pleased to offer financial assistance to patients with limited resources and inadequate medical insurance coverage. Eligibility is determined by total family income/assets. The patient must agree to apply for other assistance available to pay hospital charges (Medicaid, Medicare, private insurance) before being discharged.

Northeast Montana Health Services - Poplar Hospital's Charity Care Policy

Northeast Montana Health Services - Poplar Hospital provides high quality care to everyone, regardless of their ability to pay.

Northeast Montana Health Services - Poplar Hospital's charity care policy includes:

• Substantial charity care guidelines that provide free care for individuals and families who earn less than 200 percent of the federal poverty level.

• Sliding scale fees to provide substantially discounted care for individuals and families who are between 200 and 400 percent of the federal poverty level.

• Hardship policy for those patients who would not otherwise qualify for charity care but have unique circumstances.

In many cases, Northeast Montana Health Services - Poplar Hospital offers interest free loans for up to one year to assist patients.

For more information, please contact our Customer Call Center at (406) 768-6100.