Occupational therapy (self-care training)
Facility: Kiowa District Hospital
Billing Code: 97535 (CPT)
- CPT Billing Code: 97535
- Insurance Median: $86
- Cash Discount Price: $101
- vs. Medicare Baseline: 2.65x Medicare
Average discount available for prompt cash payment at this facility.
Median negotiated contract rate across all mapped commercial carriers.
Standard federal government reimbursement rate for this code.
Visual Cost Comparison vs. Medicare
Understanding this gauge: We use the federal Medicare rate of $32.4 as the cost baseline. Rates below the baseline represent excellent value. In-network commercial rates commonly hover around 150% - 250% of Medicare, while rates exceeding 300% are elevated. Hover over the green and blue markers to view detailed calculations.
Elevated Commercial Rate Alert (Value-Gap)
The negotiated rate at this facility is 265% of the Medicare baseline (a markup of 165%). Patients with high-deductible plans or out-of-network benefits may face excessive out-of-pocket costs.
Out-of-Pocket Cost Estimator
Estimate whether it is more economical to use your insurance or pay the upfront self-pay cash rate.
Commercial Insurance Negotiated Rates
Negotiated contract ranges established by major commercial carriers at this facility.
| Carrier / Plan Group | Contract Rate Range | vs. Medicare Reference |
|---|---|---|
| Tricare | $26 - $72 | 80% |
| Blue Cross Blue Shield | $34 | 105% |
| Healthchoice-All Plans | $51 | 157% |
| UnitedHealthcare | $54 - $185 | 167% |
| Health Partners Of Ks-All Plans | $59 - $163 | 182% |
| Humana | $60 - $167 | 185% |
| Multiplan-All Plans | $63 - $174 | 194% |
| Gbs Insurance - All Plans | $63 - $174 | 194% |
| Medicare (plans) | $64 - $176 | 198% |
| Triwest-All Plans | $64 - $176 | 198% |
| Aetna | $64 - $176 | 198% |
| Medicaid / KanCare | $67 - $185 | 207% |
| Providers Care (Wppa)-All Plans | $100 - $278 | 309% |
| Liberty Healthshare-All Plans | $108 - $299 | 333% |
Consumer Guidance & Cost Commentary
For the CPT code 97535, Occupational therapy (self-care training), the gross charge at Kiowa District Hospital is $126.00. While the facility's cash median rate of $101.00 is lower than the gross charge, it is important to note that commercial insurance negotiated rates often exceed this cash price due to administrative overhead and contract structures. For instance, UnitedHealthcare and Medicaid/KanCare have negotiated ranges starting at $51 and $100 respectively, which can be higher than the cash rate if a patient has a high deductible. Patients should verify their specific plan's allowed amount before scheduling, as assuming in-network status guarantees the lowest price is a common pitfall. Additionally, since the facility is a Critical Access Hospital in Kiowa, KS, patients should explicitly ask about "prompt-pay" discounts, which can reduce the final balance by 20% to 50% when paid upfront, bypassing costly insurance billing cycles.
When evaluating the cost of this service, it is crucial to compare rates against the Medicare benchmark rather than the hospital's inflated chargemaster list. The Medicare amount for this code is $32.40, which serves as the scientifically validated baseline for fair pricing. Commercial rates typically average 200% to 300% of this Medicare rate, whereas fair pricing is generally defined as 120% to 150%. Although specific county or state average data was not provided in the source material, patients should request an itemized billing audit if they receive a summary bill, as over 80% of hospital bills contain errors such as double-billing or unbundled codes. Finally