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Surprise Medical Bills: 5 Paths To Preventing These Headaches

You’ve been here before. Standing at the mailbox, holding a doctor’s bill that’s triple the cost you were expecting. You can almost hear your wallet sobbing.

How does this happen? Don’t blame yourself. Medical billing is so complex that people literally have to go to school to understand it. And even the specialists can get it wrong.

So, how do you fight surprise medical bills? There are ways, but it takes some planning.


Keeping Surprise Medical Bills Out Of Your Life

Here are some strategies to protect your bank account, and your sanity.


1. Know What’s What About Health Insurance

If you have health insurance, you’ll have copays, coinsurance, and deductibles. This is how the insurance company “splits the bill” with you.

Every health insurance plan has different dollar amounts for those things. Find out what yours are. It will help prevent surprises.


2. Get Estimates Ahead Of Time

For a planned procedure like an MRI, knee replacement, or removal of a mole, you should be able to get a pretty good idea of what you’ll pay. That’s not to say you’re going to like it. But at least you’ll know.

Here’s how to do it. Ideally, have your doctor provide you with the exact billing code(s) for your procedure. That means the codes for the surgery, the blood tests—everything.

Next, call your health insurance company and give them those billing codes. The company can tell you:

  • Which hospitals (or other providers) to use, for the lowest prices
  • How much they (the insurer) will pay
  • How much you can expect to pay

Does it take time? Sure, but it beats getting charged thousands of dollars you didn’t expect. Think of it as being your own financial advisor.

Not insured? Ask your doctor about other options. Maybe there’s a discount community clinic in your area. Or maybe your hospital can provide financial aid.

And there are definitely non-profit groups that help people pay their medical bills. Call one of them ahead of time and tell them what you’re facing.


3. Get Smart About Your Network

If you’re insured, certain providers (doctors, specialists, and other health providers) have set up contracts with your health insurance company. That’s your network. Bottom line—you get the lowest charges with these providers (“in-network”).

An out-of-network provider is someone outside of that network. They’ll charge more. So, ask your insurance company to refer you to in-network providers only.


… And Especially About Balance Billing

Be aware that sometimes, hospitals can bring in out-of-network providers on your case, without telling you. Which is scary, but it happens. Here are some examples:

  • A radiologist who reads your MRI results
  • An anesthesiologist who puts you under for surgery
  • A pathologist who interprets your lab results
  • A specialist who’s brought in to consult on your case, like a cardiologist
  • Neonatal units, which might be in a different network than the hospital where they’re located (another example how complex health care can be)

All of these providers can be out of your network. What happens? You pay a heftier bill.

Usually, it’s the difference between what the out-of-network provider charges, and what your insurance company would pay an in-network provider for the same thing. That’s called balance billing.

For example, say you’re in the hospital after heart surgery. An out-of-network cardiologist is brought in to consult on your case. Your bill might say:

$2,000 (what the cardiologist charged)

– $1,200 (what your insurance company actually paid, because that’s what it would pay an in-network provider)


$800 (what you now owe that out-of-network cardiologist)

Balance billing is not uncommon. And about one-third of Americans have received a medical bill where their insurance company paid less than they expected.

So, yes, it could happen to you. What can you do to prevent balance billing? Ahead of time, talk to your insurance company, the doctor, and the hospital. Arrange to have only in-network providers if it’s at all possible.

If you do get balance billed, call your insurance company before sending any money to the provider who billed you. Depending on your plan and what kind of care you received, the insurer may be able to get your bill reduced.

If not, call the out-of-network provider’s office, and explain what happened. That cardiologist, for example, might be willing to forgive at least some of your debt.

Currently, California, Colorado, Connecticut, Florida, and New York have a few protections against balance billing, And some states require HMOs to protect their members from balance billing, especially for emergency care. Call your state’s insurance regulator to see if you have any protections.

What about if you have Medicaid or Medicare? Generally, those plans protect you from balance billing. You probably won’t have to worry about it, but check your bills for accuracy.

surprise medical bills


4. Ask For A Breakdown (Instead Of Having One Later)

When your medical care is finished, ask the hospital for an itemized bill. It’s a breakdown of all the tests, procedures and other services you had.

Look for anything you don’t recognize, and ask the hospital about it. Hospitals can make mistakes, too. If it was care they never gave you, your insurance company can probably help you get it deleted from the bill.


5. Get An Advocate

Medical billing advocates help people sort out medical bills, talk to providers and insurance companies, and can figure out if your rights are being violated. This service could be pricey. But there are also nonprofits that help.

Here are some places to start:

Again, all of this might seem like a lot of fuss. But is it worthwhile? Definitely. It can empower you, make you smarter, and boost your confidence. It could also save you hundreds or even thousands of dollars. And that’s something you can take to the bank.

Do you have a friend or relative who’s freaking out over a surprise medical bill? Share this article with them.