Recent regulations have promoted health care price transparency, but determining what a medical procedure will actually cost can still be surprisingly difficult. Wide variation in network contracted rates can make it challenging for plan members to identify high-quality, lower-cost care. For self-insured plans, those differences can also translate directly into higher claims costs. Medical management services can help members understand their options and make informed care decisions based on both quality and cost.
Why Health Care Comparison Shopping Isn’t Easy
In theory, finding quality care at the best available price shouldn’t be too challenging. You compare prices for the services you need, make sure the hospital or clinic accepts your insurance, check your copay and make an appointment at the site that offers the best balance of quality care and affordability.
But scheduling a medical procedure is not like buying a new phone or car. If you have insurance, you’re not just dealing with a single organization. You’re navigating both the health care provider and the health plan. Health care pricing and insurance networks are complex, and interpreting hospital billing codes, contracted rates and network requirements often requires specialized knowledge.
Federal transparency requirements are intended to help. The Hospital Price Transparency rule requires hospitals to publish prices, and the Transparency in Coverage rule requires health plans to publish in-network rates and out-of-network allowed amounts. Even with these transparency requirements, navigating health care prices can remain difficult. Research from the Pennsylvania Health Access Network concluded that difficult-to-use formats, missing prices, unreliable data and unfamiliar procedure codes make comparison shopping difficult.
Informed Decisions Can Help Control Health Care Spending
As health care spending rises, plans and the members they serve are looking for ways to manage costs without sacrificing quality or discouraging beneficial care. Helping members identify high-quality, lower-cost providers is one of the most direct opportunities.
The difference in cost can be substantial. To see exactly how much prices vary, the Health Care Cost Institute (HCCI) analyzed Transparency in Coverage data to compare the prices for childbirth at different hospitals in Pennsylvania in 2025. To make the comparisons meaningful, HCCI only looked at the most common childbirth admission type: vaginal delivery without complications.
The differences in price were striking. Across Pennsylvania metro areas, the median negotiated price ranged from $5,505 in the lowest-cost market to $12,244 in the highest-cost market, meaning the difference was more than twofold. The differences in price within the same metro area could be even greater depending on the specific hospital. In Philadelphia, for example, negotiated prices ranged from $4,100 to $24,323.
One particularly notable finding is the variation in price within the same hospital. HCCI found that the same service at the same hospital could have different prices depending on the insurer, and the highest price was an average of 1.9 times more expensive than the lowest price. At some hospitals, the highest price was nearly five times more expensive.
Other researchers have found similar variation. A study published in the Interactive Journal of Medical Research used Transparency in Coverage data to look at prices for a number of common services. For the top 20 billing codes, the variation between the minimum and maximum rates worked out to an average of 40% of the Medicare rate.
Another study, published in the JAMA Health Forum, found similar variation for major hip and knee joint replacements. Researchers identified 1,756 UnitedHealthcare negotiated rates across 1,124 acute care hospitals, with rates ranging from $11,203 to $106,427, a nearly tenfold difference.
Greater Transparency Benefits Plans and Members
Greater pricing clarity can benefit everyone involved in care. It can help providers reduce billing confusion, help health plans better manage costs and help members understand their financial responsibility before receiving care. But transparency alone does not necessarily make health care easy to navigate.
Prices are negotiated between the provider and the insurer, and this means that variation exists within the same network for the same service and within the same facility between different networks. Even when a medical procedure goes exactly as planned, with no additional services needed, the health plan member may not know the cost until the bill arrives.
Uncertainty about health care costs can be a source of stress for members who need care but worry about unexpected expenses. For self-insured employers, large variations in contracted rates can also make it harder to manage plan spending, particularly when members have multiple in-network options for the same service.
Policymakers continue to pursue additional price transparency measures, including the Patients Deserve Price Tags Act. At the same time, existing transparency data is already creating opportunities for plans to help members make more informed decisions.
At ICM, we use price and quality tools to help members understand their options and identify lower-cost, higher-quality providers within their network. But providing data is only part of the solution. With so many factors affecting health care prices, members may benefit from personalized guidance that helps them understand their choices and feel confident about where they receive care. Learn how ICM’s medical management services can help your members navigate care with greater confidence.