Know what you’ll have to pay before a health procedure

It’s frustrating to get a surprise medical bill. This happens most often when you’re in the hospital and someone who helps treat you isn’t in your health plan’s network. If you have surgery, for instance, the hospital and surgeon could be in your network, but the anesthesiologist might not be. The surgeon and hospital have agreed to a discounted rate with your health plan and can bill you only for coinsurance and copays. The anesthesiologist, however, can also bill you the difference between what the insurance company pays and the anesthesiologist’s normal rate. When this happens, it’s called “balance billing.” Here are some other times you might get a surprise medical bill:

  • You have a treatment or procedure that your health plan doesn’t cover.
  • You have tests at your doctor’s office and your doctor sends the tests to an out-of-network lab or specialist.
  • You go to the emergency room and the doctor who treats you isn’t in your network.
  • You go to an out-of-network doctor or specialist for routine care.
  • You use an ambulance or air ambulance to take you to the hospital. Ambulance services are usually out of network and may bill you for amounts that your insurance company doesn’t pay.

The best defense against surprise medical bills is knowledge. Know what your health plan covers. And know beforehand who is going to treat you and whether they’re in your plan’s network. Avoid using out-of-network providers if you can.

Ask your doctor:

  • What treatment or procedures do I need?
  • Will I have to go to the hospital? If so, is it in my network?
  • What’s the estimated cost?
  • Do you send my tests to someone else to get the results? If so, who do you send them to?

Ask the hospital or emergency room:

  • Do you take my insurance?
  • Who will be assigned to my care? Are they in my network?

Ask your health plan:

  • Are the treatments or procedures I need covered?
  • Do I need approval before I have them?
  • How much will I have to pay?

Other tips to help you avoid surprise bills

  • When you schedule an appointment with a doctor, ask whether the doctor takes your insurance. Call your health plan and verify. Don’t rely on printed or online provider directories. They could be outdated.
  • If you have a primary care physician, be sure to get a referral before you go to a specialist. If you don’t get a referral, you might have to pay the full cost yourself. There are some exceptions. Women don’t need a referral to go to an OB/GYN, for instance. Check with your health plan to find out whether you need a referral.
  • If you have blood tests, X-rays, or other tests at the doctor’s office, ask whether they’ll be sent to a lab or specialist. Ask the doctor to use labs and specialists in your network if possible.
  • If you have to go to a lab for tests, make sure the lab is in your network. If it’s not, ask your doctor whether there’s an in-network lab you can go to.
  • If you’re in the hospital, ask your care coordinator to assign only providers who are in your network to your care. If that’s not possible, ask which providers will be out of network.
  • Ask the out-of-network providers for an estimate of their charges. Try to negotiate a lower charge up front. You probably won’t be able to do this for emergency care.
  • Know which hospitals and emergency care centers near you are in your network. Go there if you can. If you end up being admitted, you won’t get a bill for an out-of-network hospital stay.
  • If you use an ambulance, ask to go to a hospital in your network, if you can. Most ambulance services are out of network, and their charge is usually based on how far they take you. Your health plan will probably pay for some of the bill, but not all of it.
  • Ask your health plan if it will pay for your prescriptions. Health plans have lists of prescriptions they will pay for. If your doctor prescribes a drug that’s not on your plan’s list, you might be able to get a coupon for it or join a free discount drug program. Search the internet for the name of the drug to find coupons and discount programs.
  • If you get a surprise bill, review it carefully. Make sure that you received all the services listed.

Note: Even with planning, you could get a surprise medical bill. To learn how to get help with a surprise bill, visit our Handling Surprise Bills page.

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Last updated: 04/11/2018