One New Jersey hospital submitted $440 million in charges to Medicare in 2023. Medicare paid $15.7 million. That's a ratio of 28 to 1, and it's the highest in the country among hospitals with at least 500 discharges.

Capital Health Medical Center in Pennington, NJ posted a charge-to-payment ratio of 28.03, meaning it billed Medicare roughly $28 for every dollar it actually received. The second-highest ratio belongs to another New Jersey hospital, Capital Health Regional Medical Center in Trenton, at 26.51. A third New Jersey facility, Carepoint Health in Bayonne, rounds out the top three at 20.28. New Jersey accounts for 3 of the top 25 hospitals by this metric, with all three exceeding a ratio of 20.0. No other state comes close to that concentration at the extreme end.

These numbers don't reflect what Medicare actually pays. They reflect what hospitals choose to ask for. The gap between those two figures is the story.

The Top of the Distribution Has Pulled Away From the Middle

This isn't just a story about a handful of outliers. The entire upper tail of the distribution has moved.

In 2013, the 90th percentile charge-to-payment ratio across all hospitals was 7.26. By 2023, it reached 9.38. The median grew too, from 3.95 to 4.86, but more slowly. The ratio of the 90th percentile to the median, a measure of how far the aggressive billers have separated from the typical hospital, grew from 1.836 to 1.931 over that decade.

At the very top, the 99th percentile ratio reached 15.71 in 2023, up from 10.78 in 2013. That's a 46% increase in a single percentile that was already far above the norm. For context, a hospital at the 99th percentile in 2023 is billing Medicare nearly 16 times what it receives. The median hospital bills roughly 5 times what it receives.

The practical consequence: as the spread between aggressive and typical billers widens, the hospitals at the top become increasingly difficult to benchmark against the rest of the industry. A ratio of 28 doesn't just look like an outlier. It's operating in a different category entirely.

Volume Amplifies the Numbers

High ratios become more consequential when paired with high discharge volumes. CJW Medical Center in Richmond, VA had a charge-to-payment ratio of 16.96 and submitted $1,480,732,530 in charges across 7,590 discharges, the highest total submitted charges among the top 25 hospitals. Medicare paid $87.3 million of that. The remaining $1.39 billion in submitted charges was, in effect, a billing fiction for Medicare purposes.

The per-discharge figures reveal another dimension. Doctors Medical Center in Modesto, CA averaged $20,720 in Medicare payment per discharge. HCA Florida Twin Cities Hospital in Niceville, FL averaged $7,264. Both appear in the top 25 by charge-to-payment ratio, but the underlying economics are different: one is a high-acuity facility receiving relatively generous reimbursement, the other is collecting far less per case while still submitting charges at a ratio of 16.49.

That distinction matters because charge-to-payment ratios don't exist in isolation. A hospital serving a sicker, more complex patient population may receive higher Medicare payments and still post a high ratio if its chargemaster prices are set aggressively. A hospital with low Medicare payments per discharge and a high ratio is a different kind of signal.

What the Chargemaster Actually Does

Medicare's fixed payment rates make the submitted charges largely irrelevant to what the program pays. But those same charges are the starting point for negotiations with commercial insurers, and they're the prices uninsured patients see on their bills before any discounts are applied.

A hospital with a 28-to-1 ratio isn't extracting 28 times the Medicare rate from every payer. But it is establishing an anchor that affects every non-Medicare negotiation and every self-pay patient who doesn't know to ask for a discount. The 475 hospitals that dropped out of this analysis between 2013 and 2023 (from 3,058 to 2,583) may reflect consolidation, closures, or data reporting changes, but the hospitals that remain are billing more aggressively at the top than they were a decade ago.

Given that the p90-to-median spread grew from 1.836 to 1.931 between 2013 and 2023, what specific billing strategies or market conditions explain why hospitals like Capital Health, with a ratio of 28.03, have diverged so sharply from the median hospital's ratio of 4.86 is a question the charge data alone can't answer. But the distance between those two numbers keeps growing.