How to Avoid Surprise Medical Bills

Surprise medical bills are an increasingly common occurrence that result when your insurance doesn’t cover a medical professional visit or procedure. An unexpected bill could cost you thousands, whether it’s because you haven’t met your deductible, seen an out-of-network specialist, or have to undergo an unplanned procedure that’s not covered. Take the time to understand who your medical providers are beforehand. Call your insurer to verify your coverage options, and come up with emergency plans to prepare for unplanned procedures in advance. If you do get stuck with a bill, be sure to check for clerical errors, find a patient advocate, and negotiate with your provider.

Method 1 - Doing Your Research

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→ Know your deductible and other plan details. You can log into your insurer’s website or call their helpline to find out about your plan’s specifics. More plans today have a high deductible, which is the amount of money you must pay in medical expenses before insurance covers costs.

→ Having a high deductible reduces monthly premiums, but remember you won’t be covered until you meet the deductible out of pocket. In addition, premiums don’t count toward your deductible.

→ If you can’t afford a procedure, discuss the potential consequences of skipping the procedure with your healthcare provider. If possible, consider having it done after the next time you sign up for insurance. When you search for a plan, sign up for one that has a low deductible, if any at all. Your premiums will be higher, but you could save thousands in the long run.

→ In addition to the deductible, check your policy to see if out-of-network providers are covered, and how much more expensive they are than an in-network provider. Doctors and other medical professionals will either be in your insurance network or out of it, and some policies won’t cover the cost of seeing an out-of-network provider at all.

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→ Select a plan that covers your prescriptions. If you have a chronic condition, make a list of all the prescription medications you take. When shopping for a plan, check to see if it covers your medications and first-tier generics. Also, find out if there are alternative medications that may be prescribed for your condition and are that are covered under the plan. Call that potential insurer to double check coverage before enrolling.

→ If your doctor writes you a new prescription, ask them about its cost and what generics are available. Ask if they have samples on hand to help reduce your cost. Shop around by calling different pharmacies, as prescription prices can vary from one pharmacy to another.

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→ Call your insurer before visiting any medical professional. Whether you’re going in for a checkup, getting blood drawn, or undergoing any other medical procedure, contact your insurer with the name and location of your medical professional. Don’t simply call the doctor or other care provider, as they may not be as up to date about the insurer’s coverage as the insurer itself.

→ Ask your insurer, “Is my doctor in my network? If not, can you refer to me to another local, in-network option?” Ask the person you speak to for their name and information. Keep a record of everyone you talk to and what information they give you.

→ If your doctor refers you to a specialist, such as a dermatologist or cardiologist, call your insurer before going to the appointment to make sure the specialist is in-network.

→ Never see a medical professional without making sure you’re covered. Going in blind could cost you hundreds or thousands of dollars, and you will most likely be unable to contest the charge.

Method 2 - Reducing the Cost of Planned and Unplanned Procedures

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→ Make sure all your healthcare providers are in-network before surgery. Be extra diligent about doing your research before going in for surgery. Since so many medical professionals will be involved, you should take the time to learn exactly who will be performing any aspect of the procedure and what your coverage options are. Remember that even if your hospital is in-network, the medical professionals involved with your surgery might not be.

→ Call the hospital ahead of time. Ask them the name of your surgeon, the anesthesiologist, lab, and any other specialists who might potentially offer consultation. Give them your policy information and ask which medical professionals are in-network. Ask that you only be seen by in-network providers. Then call your insurance provider to verify the information your hospital gave you.

→ If only out-of-network providers are available, shop around for another hospital. If no other options are available, or if you prefer to see an out-of-network expert, call your insurer to negotiate coverage options. In addition, call the out-of-network provider to see if they will make an exception and accept your insurance.

→ If you have no success with negotiation, ask the out-of-network provider if they will accept a lower rate since you are paying out of pocket. There’s no harm in trying. Ask them to set up a payment plan beforehand and make sure you understand how much you will owe.

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→ Ask your insurer if a procedure must be pre-approved. Some procedures, like an MRI or CT scan, must be approved beforehand or insurance won’t cover them. If your doctor orders any test, consult your insurer before the appointment.

→ Say to them, “My doctor has ordered an MRI at this lab at this location. Does this procedure need pre-authorization? Does my plan cover this test at this location?”

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→ Develop emergency plans ahead of time. It might be a lot of work and strange to think about, but do your best to create multiple action plans in case of any emergency. Get in touch with both area hospitals and your insurer to compile a list of in-network cardiologists, general surgeons, orthopedic surgeons, anesthesiologists, and other emergency room personnel.

→ Do your best to know exactly who you would see and who would be covered if you had a heart attack, broke your leg, or any potential emergencies you might suffer, especially if you have any chronic disorders that put you at a higher risk of needing emergency care.

→ Keep your action plans handy, and keep your spouse, immediate family members, and other emergency contacts informed about your plans. If you are conscious during a medical emergency, do your best to have someone drive you to the hospital that you’ve identified as employing the most in-network professionals. Reserve ambulances for absolute emergencies.

→ Before paying any bills due to unplanned emergency care, get in touch with patient advocate groups and call the medical professional or hospital to see if they will take your insurance or offer a lower rate.

Method 3 - Dealing with a Surprise Medical Bill

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→ Ask for an itemized statement. As soon as you receive an unexpected medical bill, call the care provider and ask for an itemized statement. Call the hospital or provider for help understanding each item line. The itemized bill will be your most vital resource during each step of the process: error checking, getting an advocate, contesting, and negotiation.

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→ Check the itemized bill for errors. Does the statement include a hospital stay for an extra day, when you can verify that you were released earlier? Have you been charged for an extra half hour in the operating room? Does the bill charge for a medication administered through Friday but you know your IV was taken out on Wednesday?

→ If your insurer rejected a charge but the procedure and medical professional were both covered, call your insurer to rule out any coding errors.

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→ Consult a patient advocacy group. Surprise medical bills are a common occurrence in the United States and there are many organizations that can offer you assistance. Find the right advocacy agencies for help understanding your bill, to launch a complaint, or to contest a bill or file an appeal with your insurer. Be sure to ask any advocacy group you contact if they charge for their services or if they offer free assistance.

→ Get in touch with the Patient Advocate Foundation for assistance with mediation, arbitration, co-pay relief programs, and online informational resources: http://www.patientadvocate.org/.

→ Look to Families USA for links to state-based advocacy groups and state government health advocates: http://familiesusa.org/health-action-network.

→ Check the National Association of Insurance Commissioners website for more information about your state’s insurance regulations: http://www.insurance.naic.org/state_web_map.htm.

→ Search online for your state’s medical board to launch a complaint against a doctor.