Most of us know by now that our medical care will cost a lot less if we see a doctor who participates in our health plan’s network.
But it’s gotten harder to know for certain which doctors participate and which don’t, particularly if you’re hospitalized. For example, if you visit the emergency room you likely won’t know if the doctors treating you are in your plan’s network. Even if you have surgery or deliver a baby at an in-network hospital, you could be treated by an anesthesiologist or an assistant surgeon who is not contracted with your insurer.
Even if your insurer reimburses out-of-network doctors, the doctor you saw may decide the payment wasn’t enough, and send you a bill for the balance.
That’s when surprise bills show up. According to a recent report by Consumers Union, nearly one-third of Americans with private insurance got a surprise medical bill in the last two years.
So, if you’re planning a surgery or procedure, consider these 5 steps to reduce your risk of getting surprise bills:
1. Know what your plan covers. Surprise bills can often be avoided by simply taking the time to carefully read through your plan’s benefits and by calling your insurer to ask whether the procedure you need is covered.
2. Get the names of your providers. “You should have a firm understanding not only of what is involved in the procedure you’ll be having, but who will be involved in providing your care,” says Dr. Sam Ho, chief medical officer for UnitedHealthcare.
Get in writing the names of all the healthcare professionals providing your care and make sure they are all in the network, including physician assistants, anesthesiologists, and radiologists. “You have the right to request only in-network providers,” Ho says.
3. Call about your health plan. Provider networks change all the time. Before your procedure, get in touch with your health plan to verify that the doctors you plan to see are still in-network, and be sure to take notes on who you spoke with and what you were told. If you receive an unexpected bill after your procedure, contact your health plan again for assistance.
“Some insurers will serve as an advocate on your behalf and negotiate with the physicians to either lower the out-of-network charges or waive them all together,” Ho says.
4. Ask about cost. There are a number of pricing tools available today that can help you research the estimated cost of specific treatments and procedures. Most insurers offer price estimate tools, as do many large employers. There are also plenty of apps and websites available.
Keep in mind, however, that there is no comprehensive database of healthcare prices.
And, despite all the tools, finding accurate healthcare cost information is still generally difficult.
Still, it pays to talk with your physician and/or the hospital about the cost of your care and to request an estimate in advance.
If you receive a surprise bill, ask if your provider will accept your health plan’s payment as payment in full.
5. Know your state’s rules. Federal law does not protect patients from surprise billing. But some states have policies in place that help people with at least some of the common situations that lead to unexpected charges, such as emergency room visits that involve out-of-network doctors.
If you receive a surprise bill, contact your state’s department of insurance to see if there are legal protections against balance billing.