Bills of any variety are typically greeted with groans, but unexpected medical bills are particularly unwelcome. Often, they hit your mailbox weeks, even months, after your doctor visit or the date of a procedure. And while these bills may be an unpleasant surprise, they’re not all that uncommon.
One 2018 survey done by NORC at the University of Chicago, a non-partisan research organization, found that 57 percent of respondents had received a bill they thought would be covered by their insurance provider.
“Being hit with a surprise bill can be financially devastating and cause great anxiety,” says Bari Talente, executive vice president of advocacy at the National MS Society.
But here’s the good news: You can prevent many unexpected medical bills just by taking a few extra steps before your appointments. Here are some simple strategies patient advocates and insurance experts recommend.
1. Study up!
Every January, your health insurance shares a giant package full of details about your plan. The font may be small, and the language dense, but experts agree: Reading—and absorbing—this information is a must.
“Understanding your coverage is up to you,” says Tamara Sieger, patient advocacy director for Alliance in Reconstructive Surgery Foundation. “Don’t assume that insurance will or should cover particular procedures,” she says. Instead, wade through that fine print, so you’ll gain a solid grasp on your plan’s benefits and its limitations, Sieger says.
It may help to highlight the important parts as you read through everything. Take note of what the plan’s deductible is—that’s the amount you need to pay during a coverage period (usually one year) before your insurer will cover costs. If your plan’s deductible is $500, for instance, then you’ll pay claims until you’ve hit that amount; after that, your insurance will cover claims for the rest of the coverage period.
You’ll also want to know which services are covered in-full. For some preventative or essential services (think: the flu shot, your annual physical, etc.) all you’ll owe is a co-pay, and your insurance will foot the rest of the bill. These are basically freebies, so you’ll def want to take advantage.
2. Stay in-network.
Here’s how insurance works: Insurance providers create a network of healthcare providers, labs, hospitals, and so on, that are covered. Go outside that coverage network, and you’ll bear a bigger financial burden, Sieger says. That’s because the insurance company has negotiated rates with in-network providers.
For out-of-network providers, the insurance company has no agreement, so if the health care provider charges a higher rate, the insurance will only cover the amount they’ve established with their in-network providers, leaving you to pay the difference. (Womp, womp!)
To play it safe, always check if a provider is covered before showing up to an appointment. Talente recommends taking a screenshot of the insurance website where the provider is listed for documentation in case there is a dispute in the future.
Before a procedure, you’ll need to check what’s covered even more thoroughly. Maybe the surgeon is in-network, but you should also determine if the facility, the anesthesiologist, and the equipment, are covered by your plan, says Teri Dreher, RN, iRNPA, a board-certified patient advocate and the owner and CEO of NShore Patient Advocates. If your doctors want to use robotic surgical equipment, for example, your insurance could consider it non-essential for the procedure and refuse to cover the cost.
3. Ask questions—and lots of them.
Even if you go to an in-network doctor or facility, keep asking questions about coverage. “Asking a doctor or physician if your insurance covers specific treatments is a must,” says Shawn Plummer, an insurance marketer with Unkefer & Associates. If during your appointment your doctor wants to do a blood test, an EKG, or any other procedure or test, ask if it’s covered—and what the doctor charges.
If the doctor is unsure, you can ask for the Current Procedural Terminology (CPT) code, then call your insurance to find out if the procedure is covered. Your insurance may cover one type of mammogram, for instance, but not another. Having the specific CPT code will help you track down the definitive coverage details.
4. Compare costs.
Does your doctor send blood work out to multiple labs? Do you have several pharmacies nearby? Sometimes, one may be more cost-effective than another.
“Your insurance company can advise you of preferred labs, pharmacies, and providers who may save you money,” Sieger says. A phone call to your insurance company to compare pricing or inquire as to preferred facilities could wield significant savings—and prevent a higher-than-necessarily bill.
You can also use a price comparison site—such as Clear Health Costs or FAIR Health Consumer—to get an estimate of costs for a procedure and compare what's available in your ZIP code.
5. Get preauthorization.
By now, it’s likely clear: The best way to avoid unexpected medical bills is to put in the legwork beforehand. That’s particularly true when it comes to procedures.
Most insurance plans require preauthorization for surgery, notes Dreher, who recommends asking your doctor for written confirmation of coverage. “Failing to have procedures preauthorized with insurance may result in penalties and non-covered procedures,” notes Sieger.
6. Plan ahead for an emergency.
The best-case scenario is that you do not have any medical emergencies. But plan ahead, just in case. If something does go wrong, you won’t have time to log on to your insurer’s website or call them to discover which hospitals are covered.
When you have some free time, look into which nearby hospitals are covered by your health insurance, recommends Talente. Spend a few minutes to review your coverage for ambulance services, too. A recent study published in JAMA Internal Medicine, found that 85 percent of ambulance usage resulted in an out-of-network bill.
In an emergency, the most important thing is to get the care you need. But in non-life threatening situations (maybe you need transportation from one hospital to another), you can ask if it’s possible to get an ambulance service that’s covered by your insurance.
7. Document, document, document.
A simple phone call can help answer a lot of important questions: Is this procedure covered? Is this doctor in-network? What is the insurance plan’s preferred lab? But even after you get answers and confirmation, there’s one further step that experts recommend taking: Get it all in writing.
Whether it’s a conversation with a patient advocate, the doctor’s billing department, or a patient representative, always ask to have the information sent over in writing, says Dreher. This way, you can dispute any charge that doesn’t seem right.