6 Ways to avoid surprise medical bills

Medical procedures can cost a lot, even if you have excellent insurance. The financial hit is even harder when you get a bill you didn’t expect — which is more common than many people realize. One recent study looked at patients who’d had elective surgery at an in-network hospital with an in-network surgeon. It found that 20% of the patients received out-of-network bills.

“You can think that you’ve done everything right in terms of planning and still have surprise costs,” says Adria Gross. Gross is founder and CEO of MedWise Insurance Advocacy in Monroe, New York. And the costs are significant: Having a surprise out-of-network medical bill raised the total cost by an average of $14,083. 

In the same study, surprise bills most often came from anesthesiologists and surgical assistants. While the hospital might be in-network, these specialists — among many others — might not work for the hospital, but simply treat patients there. 

The good news? Many of these bills may soon be a thing of the past. A bill passed by Congress in December 2020 should help prevent surprise medical bills. The legislation essentially bans what’s called “balance billing.” This is when the patient is billed for the difference between a provider’s charge and the insurer’s allowed amount. The law will go into effect in January 2022.

But even with these protections, many patients may still find themselves staring at surprise medical bills. Here’s how to make sure you’re not one of them.

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It’s important to check with both your medical provider and your health plan to make sure the provider is in-network. “Don’t rely just on your health plan. Sometimes their directory isn’t up-to-date,” says Gross. If your doctor’s office isn’t sure, ask to speak to someone in their billing department for a definitive answer, says Gross. Ideally, this should be in writing.

Do the same with the medical facility where you’re having your procedure done. And check with any specialists who may be involved in your procedure. 

Other medical groups that contract with the facility to provide medical services may not contract with your insurer, says Davis Liu, MD. Dr. Liu is chief clinical officer of Lemonaid Health and author of The Thrifty Patient. As a result, they’ll be considered out of network.

Keep a record of all the providers that you spoke to or emailed with. Include the date of communication and the information you received about the provider’s network status. That way, if there’s any dispute, you’ll have proof that you checked that all the providers are in-network.

Many health insurance companies offer the Wellframe app as a free benefit to their members. To find out if you have Wellframe, reach out to your care provider.

Many health plans cover 100% of preventive care such as mammograms or colonoscopies. But they may not always cover new technologies, such as 3D mammography. Before your procedure, always ask your doctor what the billing code is. Then call your insurer to make sure it’s covered. If it’s not, you may be hit with out-of-pocket charges. 

Some procedures require bloodwork beforehand. But if your physician wants it done at an out-of-network lab facility, it can cost a lot more. Make it clear to your doctor, and to the hospital, that you want to stay in-network, says Gross. You can also check your health insurance company’s website. It will likely have a list of in-network labs and radiology centers. 

The cost of the surgery or procedure can vary from one facility to another. Now that you have the billing code, you can use it to get a sense of different costs in your area. Look on healthcare price-checking websites like ClearHealthCosts.com or HealthcareBluebook.com. Some health insurers also have pricing tools on their website. If you find that a provider quotes a price that’s too high, you’ll know to stay away.

Make a list of which emergency departments are closest to your home and job. Then check with both your health plan and the hospital to see if they’re in your network. Take any that aren’t in your network off your list. If you need emergency care after your procedure and call 911, ask to be taken to one of the ERs on your list, says Dr. Liu. Sometimes, the ambulance itself may not be in your health plan’s network. If that happens, contact your health plan after the fact to see if they can advocate for you. 

Any time you get a bill from a medical provider, ask for it to be itemized. That’s a bill that breaks down your total healthcare cost into single items. Use it to make sure that you’re not being billed for treatment you didn’t get, says Gross. And check to be sure that the right billing code was sent to your insurer. Even if there aren’t mistakes, you can still negotiate costs with the provider. 

Many hospitals have patient advocates who can help with that process. Your health insurance company might also offer patient advocacy support in the form of a digital health management app like Wellframe. These apps can connect you with people in your health plan who can help you with medical billing issues. Finally, says Gross, most hospitals are legally required to offer financial assistance to anyone who is eligible.