Occupational therapy (therapeutic activities)
Facility: Mitchell County Hospital Health Systems
Billing Code: 97530 (CPT)
- CPT Billing Code: 97530
- Insurance Median: $80
- Cash Discount Price: $77
- vs. Medicare Baseline: 2.28x 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 $35.07 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 228% of the Medicare baseline (a markup of 128%). 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 |
|---|---|---|
| UnitedHealthcare | $33 - $89 | 94% |
| Blue Cross Blue Shield | $49 | 140% |
| Triwest Well Mark All Plans | $69 - $76 | 197% |
| Pref Hlth Care Sytms Comm - All Plans | $73 - $80 | 208% |
| Aetna | $73 - $80 | 208% |
| First Health-All Plans | $73 - $80 | 208% |
| Auxiant-All Plans | $77 - $85 | 220% |
| Phc Leased Ntwrk Access - All Plans | $77 - $85 | 220% |
| Multiplan Ppo - All Plans | $77 - $85 | 220% |
| Health Partners Ks-All Plans | $80 - $88 | 228% |
| Cigna | $80 - $88 | 228% |
Consumer Guidance & Cost Commentary
For the CPT code 97530, representing occupational therapy therapeutic activities, the facility in Beloit, KS, lists a gross charge of $85.00. While the facility's cash median rate is $77.00 and the median negotiated rate across 11 payers is $80.00, these figures are significantly higher than the Medicare benchmark of $35.07. Specifically, the negotiated rates are 2.3 times the Medicare amount, indicating a substantial markup compared to the federal baseline. It is important to note that commercial insurance contracts often include administrative overheads that inflate the baseline price by 20% to 40%, meaning the negotiated rate does not necessarily reflect the true cost of care.
Patients should be aware that paying cash directly can sometimes be more cost-effective than using insurance, particularly if their plan has a high deductible or if the negotiated rate exceeds the cash price. For this service, the cash rate of $77.00 is lower than the median negotiated rate of $80.00. To secure the best possible price, patients should contact the hospital directly to inquire about "self-pay" or "prompt-pay" discounts, which can offer fee reductions of 20% to 50% for upfront payment. Additionally, since this facility is a Critical Access Hospital with government-local ownership, verifying the specific allowed amount for your insurance plan before scheduling is crucial to avoid unexpected balance billing or deductibles that could result in higher out-of-pocket costs than the cash rate.