Our Methodology

HaggleCare uses publicly available federal data to benchmark your medical charges against what Medicare pays for the same services. Here's how it works.

Data Sources

We use three datasets published by the Centers for Medicare & Medicaid Services (CMS):

Medicare Physician Fee Schedule (PFS) — 2025: Contains payment rates for over 10,000 medical services, adjusted by geographic locality. The PFS covers the professional (physician) component of each service.
Outpatient Prospective Payment System (OPPS) Addendum B — 2025: Contains national payment rates for hospital outpatient services. The OPPS covers the technical/facility component — things like operating room time, equipment, nursing staff, and supplies.
Clinical Laboratory Fee Schedule (CLFS) — 2025: Contains national payment rates for laboratory tests (blood panels, urinalysis, pathology, etc.). Lab codes are paid under the CLFS, not the PFS, so this dataset is used for any lab line items on your bill.

All datasets are freely available from the Centers for Medicare & Medicaid Services.

How We Calculate Medicare Rates

The Medicare rate we show depends on where your care was provided:

Physician / Office Bills

We use the PFS non-facility rate for your geographic locality. This is what Medicare pays a physician for performing a service in their office.

Hospital / Facility Bills

We combine two rates: the PFS facility rate (what Medicare pays the physician) plus the OPPS APC rate (what Medicare pays the hospital for its facility costs). Together, these represent the full Medicare payment for a hospital-based service.

Laboratory Tests

Lab codes (CPT codes for blood tests, panels, urinalysis, and pathology) are paid under the CLFS — a separate national fee schedule. We look these up directly in the CLFS regardless of whether your bill was from a physician office or facility.

What the Markup Means

The markup number (e.g., "5.2x") shows how many times higher your charge is compared to the Medicare benchmark. For example, a 5x markup on a $500 Medicare rate means you were charged $2,500.

Typical hospital markups range from 3x to 10x Medicare rates. Markups above 3x are common but are a strong signal that negotiation is worthwhile.

Why Hospital Bills Are Higher

Hospital charges are set using a "chargemaster" — an internal price list that bears little relationship to actual costs. Chargemaster prices exist primarily as a starting point for negotiations with insurance companies.

Almost nobody pays chargemaster rates. Insurance companies negotiate discounts of 40-60%, Medicare pays its own set rates, and hospitals routinely offer discounts to uninsured and self-pay patients who ask. The listed price on your bill is almost always negotiable.

Potential Savings Range

We show two savings targets:

Conservative (low end): Negotiating your bill down to 1.5x the Medicare rate. This is a realistic target that most providers will consider.
Aggressive (high end): Negotiating down to the Medicare rate itself. While harder to achieve, many uninsured and self-pay patients have successfully negotiated to Medicare-level pricing, particularly at non-profit hospitals.

Published research and patient advocacy organizations consistently report that Medicare rates serve as a credible benchmark in billing negotiations.

Limitations

OPPS rates are national averages and are not adjusted for local wage indexes. Actual hospital payments may be higher or lower depending on your area.
PFS rates are locality-adjusted using your ZIP code, but localities are broad geographic areas — not city-specific.
Medicare rates represent a benchmark floor, not a ceiling. Some services may have additional costs not captured by these rates.
Our analysis is for informational purposes only and does not constitute medical or legal advice.
Not all CPT/HCPCS codes appear in both the PFS and OPPS datasets. When a rate is unavailable, we note it in your report.

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