Unfortunately, many people are hit with surprise medical bills and fees after being treated by a healthcare provider at a clinic or hospital. Even when patients make every effort to understand their insurance policy and healthcare costs, it can be challenging to grasp detailed billing information, especially if you are in the midst of a health crisis. When medical bills arrive later, revealing the services and treatments that were not covered by insurance, you can be shocked by the out-of-pocket costs. What can you do to prevent surprise medical bills?
Medical debt is cited as the number one reason for personal bankruptcy filings in the U.S. and sky-high medical bills can leave lingering debt pain for years. You can help avoid unfair medical charges and potentially save thousands of dollars by being prepared ahead of time and knowing which questions to ask. Find the information you need to steer clear of unexpectedly high medical bills.
1. What are the costs for this test/surgery/exam/treatment?
Before you get treatment, find out from your insurer, the doctor, and/or the hospital what the costs are and how the facility you visit impacts the price. Understand your insurance policy and the medical costs and services that are covered, including how much your plan’s deductible is and how it works. If you are enrolled in an insurance plan that requires you to visit providers with their network, you will likely pay more if you choose to get out-of-network care.
2. What are the medical codes for my procedure?
Find out the exact name of your procedure from your provider, and how it’s referred to in the medical billing system (the Healthcare Common Procedure Coding System, or HCPCS). With those codes, you can do your research and talk to your insurance company about what they cover and get a medical procedure cost estimate through websites like the Healthcare Bluebook.
3. Who else will be involved in my treatment and do all of my healthcare providers participate in my health insurance plan?
Even though a hospital is in your health plan’s network, some doctors who provide services there might not be. While your doctor may accept assignment, other healthcare providers like radiologists, anesthesiologists, pathologists, and neonatologists may not. If you have Original Medicare, you are responsible for making sure that all of the providers involved in your care will accept assignment. If you are enrolled in a Medicare Advantage plan, your primary care physician will help manage your care and make certain all the medical professionals involved are within your plan’s network. Understand your plan and your options as you choose providers. You may choose an in-network hospital and surgeon, but the on-duty anesthesiologist can be out of network and your bloodwork can be sent to an out-of-network lab. This is why it’s important to know not only if the doctor you are interacting with is in your insurance network but also who else is working behind the scenes. If a healthcare provider is not in-network, you can likely end up paying higher out-of-network prices for those specific services.
For planned procedures, you can find out in advance from your health plan whether your providers are contracted and if the services you will get are covered under your policy. In case of emergencies, find out which nearby hospitals and physicians are in-network and keep a list on hand to show your first responder, caregiver, or healthcare professional. Ask specifically if the doctor or facility “participates” in your insurance plan and if provided an agreement of financial responsibility form, consider writing in, “as long as the providers are in my insurance network.”
4. Am I an inpatient or an outpatient?
If you become hospitalized and have Medicare, ask the medical professionals whether you are an inpatient or outpatient. Your hospital costs and coverage depend on your hospital status and you will likely pay more if you’re considered an outpatient. If you are being held on “observation status” then you are an outpatient. If you are being admitted, then you are an inpatient. Your patient status can change during your stay, so ask this question repeatedly.
5. Is there an extra charge for a private room versus a shared room in the hospital?
Hospitals that have both private and semi-private rooms may charge you more for the single occupancy room. If you are comfortable sharing a room for a potentially lower cost, make it clear that you did not request the private room and that you are willing to occupy a room with another patient. The extra charge for a private room or suite may not be covered by your insurance policy and you may be able to save significantly by sharing.
6. Is there a facility fee?
Some hospital-based healthcare organizations will charge a facility fee in addition to the physician, X-ray, and laboratory charges. For example, if your doctor refers you to a hospital for a colonoscopy, the hospital may charge a facility fee. This is charged to the patient by the hospital for use of their hospital facilities and equipment. Most insurance policies don’t cover facility fees, so to be prepared, or if possible, avoid this unexpected cost, ask your healthcare provider if you will be charged a facility fee or get a separate bill from the hospital.
7. Is this equipment and care necessary? Do I really need this test or procedure?
You have the option to refuse unnecessary equipment like wheelchairs, slings, and splints which can often be purchased outside of a hospital or doctor’s office for less money. You may also refuse unnecessary care. If hospitalized, ask your healthcare providers about their role and who sent them to help determine if their check-ins are necessary for your health.
8. What would happen if I waited or did nothing?
If your health situation is not life threatening or urgent, take the opportunity to find a cheaper solution. Consider seeking a second opinion and do your research before agreeing to treatment or surgery. Find out if there are recommended alternatives or options that are just as good and possibly cheaper.
9. Is this an emergency?
Avoid the emergency room (ER) unless it is truly an emergency. Sprains, sore throats, minor cuts, fevers, UTIs, back pain, pinkeye, and respiratory infections are all examples of symptoms that can be taken care of in an urgent care clinic instead of at the emergency room. Even with medical insurance, ER visits can be quite expensive, particularly if your physician turns out to be out-of-network at your in-network hospital. On the other hand, please do not hesitate to go to the emergency room if your medical crisis requires it. If you have a question regarding the emergent nature of your illness or injury, call your physician and ask for their advice.
Negotiate after your visit.
If after all precautions you were still overcharged or discovered unfair medical charges, you have options. Call the doctor’s office and ask for the charges to be explained. Find out why they charged more than what your insurance covered and why they didn’t tell you about the extra fees upfront. You may be able to negotiate or dispute your medical bill and reduce a large medical bill amount or settle on different payment terms. If you are concerned that you have been charged for unnecessary services, or for services you never received, please report the fraudulent behavior to Medicare. Contact your health insurance company with any questions about your coverage and ensure you are on the right plan for your needs.
If you are interested in making changes to your Medicare coverage, you have the option to switch to a new Medicare Advantage Plan during the Medicare Annual Enrollment Period (AEP) from October 15th – December 7th.