En español | Even if you’ve got health insurance, there’s no guarantee against getting a medical bill full of unexpected charges. In a 2018 survey on health care billing by NORC, a research organization at the University of Chicago, 57 percent of respondents said they had been surprised by a bill they thought would be covered by their health plan.
Communication, or the lack of it, is part of the problem, according to Richard Gundling, senior vice president of health care financial practices at the Healthcare Finance Management Association. “We’ve learned that sometimes health care providers are reluctant to talk about money because they don’t want patients to feel like money will affect their care,” he says. “But consumers absolutely want to know. It can be empowering.”
In a medical emergency, you may have little say in who treats you or how. But in the course of routine or planned care, patients can take the initiative.
“It is your right and responsibility to ask questions about what you will be charged for health care,” says Teresa Brown, senior director of hospital accounts at Medliminal, a company that helps businesses and consumers reduce medical costs by ferreting out billing errors. “I would do that for my plumber, I would do that for my car, and you need to do it for your health care bills.”
Here are some steps you can take to avoid getting hit with unexpected medical bills.
Stay in network
Before planned treatment, call both your insurer and the medical office to verify that the service or procedure is covered by your health plan and that the doctor or facility is in your plan’s network. Give the doctor’s office the exact name of your plan as well as your group number and member ID, as your doctor might accept only some of an insurance company’s plans.
Do the same for any facilities and specialists that will be involved in your care. Tell your primary care physician you want to remain in network for all services. If your regular doctor orders a test, call the lab or imaging center to verify your coverage. If you are referred to a specialist, call his or her office to check whether the specialist is in network.
If the lab or specialist is out of network, there’s nothing wrong with going back to your primary doctor to get an in-network referral. “Most doctors will be happy to honor this request because they know many good physicians in a given specialty,” Gundling says. “They don’t want you to get a surprise bill, either.”
Even if your plan has covered treatment by a particular provider or facility before, he adds, it’s a good idea to double-check: “A provider who was in the health plan’s network when you purchased your health plan may no longer be in the network when you need care.”
You’ll also want to verify that different facilities within the same health care system are in your network. “Many academic medical centers also have satellite facilities in nearby communities, so when your doctor says he can do your procedure in one facility or another, don’t assume that insurance will automatically pay the same rate per facility,” Gundling says.
If you do choose to go out of network for care — for example, to see a provider who is closer to home or one you already have a relationship with — ask your health plan whether it will cover any of those expenses.
Ask about the charge
When your doctor orders a procedure for you, ask what he or she charges. You may get a straightforward answer, or you may be directed to the billing office. If so, ask for the Current Procedural Terminology (CPT) code for your procedure. You’ll need this five-digit code, which doctors list on bills and insurance claims, to get accurate pricing information.
Call your insurance company with the exact procedure name and its CPT code. They will be able to look up the payment amount specified by their contract with a provider or hospital. See if you can get this information in writing so you have a record if you get billed for a different amount or a dispute arises. You may also be able to find in-network price information on your insurer’s mobile app.
Scout prices for procedures
There are online resources to help you estimate what a specific procedure or test might cost in your area. The nonprofit organization FAIR Health uses a database of 29 billion medical claims for more than 10,000 services to generate cost estimates. Another site, ClearHealthCosts, uses data from consumers, health plans, providers and its own news reporting to glean pricing information at medical facilities across the country.
Your insurer can also help you by comparing the rates it has negotiated for identical procedures at different hospitals in your area, information you can use in deciding where to seek care.
Prepare for emergencies
A little preparation can lower the risk that a sudden medical crisis will bring a surprise out-of-network bill. For example:
- Make a list of the nearest ERs and determine which ones are in your plan’s network. If you need to call an ambulance, ask to be taken to a hospital on your list (but remember, the final decision rests with the emergency crew).
- Try to find out whether local in-network hospitals employ their own emergency physicians rather than relying on contractors. If so, those ER doctors are likely in network as well.
- Look into whether ambulance service is part of your health plan. It isn't always, and emergency transport is a common cause of big surprise bills.
Know your cost sharing
Even for covered services provided by an in-network doctor or hospital, you can be surprised by a bill if you aren’t familiar with the terms dictating your share of payment. For example, you will pay in full for many medical services until you reach your health plan’s deductible for the year.
Routine preventive services such as immunizations and blood-pressure screenings are typically excluded from the deductible, meaning insurance will always pay them, minus any copay. For other covered services, your plan will start paying only once you’ve met the deductible.
Deductibles vary widely based on factors such as what the plan covers and what you pay in premiums. If you have a spouse or children on your insurance, the plan will likely have individual deductibles for each covered person and a larger collective deductible that applies to the whole family. The average individual deductible for a workplace health plan in 2018 was $1,573, according to a Kaiser Family Foundation study.
After you reach the deductible, you’ll pay coinsurance on covered services, typically a percentage of the rate your health plan negotiated with in-network doctors and hospitals. For a major procedure like surgery, the coinsurance could be considerable. You can keep tabs on your coinsurance and deductible status by calling your health plan or checking your account via its website or app.
Some doctors’ practices and hospitals offer a discount if you prepay your share of the bill for common services or procedures, such as CT scans and mammograms. If you’re interested in this option, ask in advance; the provider might not advertise this program or offer it unless requested.
Remember that your insurance company will later determine what your actual share of the bill should be. Ask the medical office about the process for getting a refund if it turns out that the prepayment you agreed to exceeds that amount. You may also want to talk to your insurer before paying in advance, as prepayment could affect how your health plan handles its part of the bill.
AARP’s Money Map can help you take control of unplanned expenses and get you on back on track to financial stability.