For patients, bosses, and people who work there
How not to get ripped off.
What cash-pay looks like next to insurance, what a company that pays its own claims can do, and a packet you can hand someone. Start with the year before a knee if you want premiums and deductibles in plain numbers.
You, with a debit card
How to shop care with cash
Pretend insurance is not in the room. You are buying one procedure. Ask for the cash price they take if you pay today — not the giant list they show people with no deal.
Name the procedure
‘Knee replacement, first time, no revision’ is something you can shop. ‘Orthopedics’ is not. Ask for the code. Compare the same procedure at a hospital, a surgery center, and a second state.
Cash price is not the sticker on the wall
Hospitals publish two opposite numbers. The giant list is the shakedown for people with no deal. The cash price if you pay today is often below what insurers ‘negotiate.’ Always ask which one you are looking at.
Shop quality and price on the same page
A cheap MRI with a sloppy read is not a bargain. Sort by quality, then pick the lowest cash among the places you would actually let cut you. Academic is not automatically better for a routine scope.
Get the extras in writing
Facility, surgeon, anesthesia, implant, pathology, and the saline bag. Surprise bills live in the lines nobody quoted.
Bosses and benefits people
If your company already pays the claims
If you have more than a couple hundred employees, you are probably already the insurer. The carrier is a rented claims desk plus a policy for the disaster year. Act like the buyer. The full walk-through is for companies that already pay the claims.
If the company pays — who keeps the leftover
What you actually buy today
Claims + TPA/ASO fees + PBM spread + stop-loss premium + broker. The ‘premium increase’ is mostly claims trend and admin, not a magical insurance product getting more valuable.
When self-fund wins
Wins when you can steer shoppable spend (imaging, scopes, joints, infusions) to posted-price sites, keep a real stop-loss for blow-ups, and stop paying two bureaucracies to argue about flu shots. Kaiser Family Foundation: most large employers are already self-funded.
When it does not
Tiny groups with one cancer case and no stop-loss. Or a TPA that still runs full prior-auth theater so you bought the risk and kept the hassle.
A one-page compare
Last year’s bills on the shoppable procedures on this site vs cash menus vs what you pay the administrator. If cash plus a disaster policy is cheaper, you do not need a federal program to start a 90-day pilot.
Households who heard about sharing
Church sharing: cheaper monthly, not a licensed card
A grandfathered church share can be about a third of the family job sticker. It is not a contract, not minimum essential coverage, and not a 2026 app. The full compare is Church sharing.
Church sharing — ministry vs the card
What you are buying
Guidelines, a monthly share, maybe a cap. No legal duty to pay your bill. The hospital often sees self-pay. Jane still exists; Classic’s shareable cap is about $250,000 unless you add more sharing.
Why it is allowed
26 U.S.C. § 5000A: 501(c)(3), a common set of ethical or religious beliefs, continuous sharing since December 31, 1999. That date froze new clubs. State commissioners still treat a duck as insurance.
What they are freezing
Not 1999 Samaritan. New copies — Jesus or not — after unpaid bills and after the marketplace lost healthy lives. A Visa at a posted door is the secular share. That is the posted hospital, not a loophole.
Operators, CFOs, anyone who asked ‘then what building?’
A hospital that posts the price
One posted price, a real hospital, not two lists on the old building. Companies that already write the checks pay the wall. A separate policy covers the crash. You do not start with your own emergency department.
Posted hospital — Cost Plus with beds
The product
Cost Plus Drugs posted a vial. Surgery Center of Oklahoma posted a joint. The posted hospital is that formula with beds: birth, a small intensive-care unit, quality you would send your kid to.
Who pays
Not only the uninsured. The company that already writes checks. A funded card so nobody wires the implant from checking. Medicare can sit on the same fee. Two lists — cash plus a secret United book — is Walgreens with beds.
Where you put it
Where the law lets you, and whether you grow into the night or take over a dying hospital. The posted hospital is the building. Direct contracts fill the schedule before the emergency-department sign goes up.
If they drop you from the insurance list
If they lock you out
Assume they drop a posted-price clinic from every insurance list. Being banned is how you stay honest. The trap is signing United just to get patients.
If they lock you out — the full page
Do not want their list
Contract the employer directly. A funded card. An independent disaster policy. Two lists — cash plus a secret book — is how Walgreens wrote the check. Never bill their network.
Who still pays
A company that already pays the claims and can name last year’s knee count, or a closed group. Not a family on Healthcare.gov on day one. They keep Blue for 2 a.m. until the door is good enough to walk into.
The order
Posted prices first. Beds next. Take over a dying emergency room or grow until the pool can carry it. Copy the campus. Congress is not coming.
Anyone who thinks a price file is the plan
How hospital monopolies actually break
Posting the price is how you get a crowd. Then three jobs at once: a clinic they do not own, more hospital beds, and a rule that cuts what they can charge. One at a time is how they pick you off.
How monopolies break — the full page
Go around them
Telephone versus telegraph. PC versus mainframe. Wireless versus copper. A posted-price clinic so you are not on United’s card. That is how they usually die.
Build more hospitals
Shale versus OPEC. Mini-mills versus U.S. Steel. Open where they cannot veto a new hospital, or take over a dying one.
Change the payment rule
Standard Oil, AT&T, Paramount. Rare. Famous. Maryland cut the hospital rate and the family premium stayed $24,000. A slice is not the system.
Employers and clinic operators
Direct care contracts
Pay the OR a posted price. Card swipe or ACH. Stop-loss never sees the MRI. That is the whole product.
What a direct contract is
A defined bundle (knee, birth, colonoscopy) at a written price, no 837 claim, no denial cycle. Surgery Center of Oklahoma–style posting is the existence proof.
What to put in the PDF
The procedure, what is included, implant brand cap, readmissions rule, who pays if it becomes a hospital stay, cash vs employer-card rate. If it is not in the PDF it will be on a bill.
How not to get ripped off by the insurer layer
If the administrator ‘rents’ a network discount, demand the allowed amount vs the cash menu on the same procedure. If the network is higher than cash, it is not a discount — it is a tax.
Anyone reading an EOB
Self-pay vs insured: the evidence pattern
On this model, commercial allowed is routinely above the cash menu. That is the opposite of the story insurance sells.
The story
‘We negotiate so you pay less.’ Sometimes true vs the giant sticker. Often false vs a real cash price — especially imaging, scopes, and outpatient surgery.
What we show
Shop floor: prompt-pay cash vs commercial vs Medicare. Backend: hospital cost to deliver. The commercial−cash gap is labeled ‘insured markup.’ RAND: commercial hospital prices as a multiple of Medicare, with Arkansas near the floor and California flagships at the ceiling.
The other list
Uninsured patients who never get a cash quote can still be billed the giant sticker — worse than insured. Ask for the cash price. Do not wander into the shakedown list.
Anyone who talks to a lawmaker
A reform argument you can hand someone
Do not start with feelings. Start with a procedure, what it costs to deliver, a cash price, an insurance price, and a source. Then ask why the insurance number is legal.
Post usable prices, not 10GB dumps
Transparency files exist and are often unusable. Maryland all-payer shows a US state can keep commercial close to Medicare. That is in the state table on purpose.
Let cash skip the claims army
US admin intensity (~10 staff per physician in whole-system models vs ~2–3 in simpler-payer countries) is not clinical quality. A posted price and a card swipe deletes eligibility, prior auth, and denial on those procedures.
Stop-loss for the tail, not for saline
Catastrophe coverage is a real insurance product. Packaging it with routine care is how the saline bag becomes a claims event. Separate them.
What this site is not
Not a named-hospital sticker extract. Numbers are modeled from public hospital multiples, wage indices, and recipe costs. Each figure is tagged sourced / modeled / guess so you can see the floor.