How to Avoid a Surprise Medical Bill

Blog

How to Avoid a Surprise Medical Bill

written by Sofie Wise Written by Sofie Wise
Sofie Wise

Sofie Wise

Sofie hopes to create a more sustainable healthcare system by empowering people to make conscious health decisions. Her interests include cooking, reading, being outdoors and painting.

Read more posts by this author.

August 17, 2018 Read Time - 6 minutes

One of the main reasons we started PlushCare was because we hated getting surprise medical bills. That’s why we give you the price up front and don’t ever send you a bill. When the rest of healthcare still sends confusing bills by mail, it’s no wonder over 100,000 patients love using PlushCare. Still, we know you may have to see a provider outside PlushCare, like a dentist, podiatrist or gynecologist, so read on to learn some smart tips for avoiding surprise medical bills.

Surprise billing is common for Americans

Even if you do have insurance, your doctor visits may not necessarily be covered in full. Unexpected surgeries, outpatient procedures, ER visits, or even primary care visits may come with unforeseen medical bills. In fact, nearly a third of the American population has received a medical bill that they did not expect, while 20% of people have visited an in-network emergency room only to find that the bill wasn’t covered because their specific doctor was out-of-network.

Here are some tips on how to deal with a surprise medical bill you may encounter elsewhere in our American healthcare system:

1. Make sure you understand your insurance policy

Your health insurance policy will dictate exactly how much you pay in medical bills, so make sure that you stay on top of it. Knowing what your deductible is, what your co-pays are, and what exactly your plan covers – before you get care – will help you prevent any unwanted bills.

Always make sure that you read any mail you receive from your insurance company and stay up to date with any policy changes that occur. This will help you manage any unexpected medical charges that may come your way and will hopefully prevent any unwanted bills.

2. Review the bill carefully for mistakes

Hospitals are big organizations that handle a lot of different billing data, so it’s actually quite common for them to make a mistake. You may have been billed for a service or procedure you didn’t receive, your bill may have the wrong date, or the provider might have mistaken your insurance information.

Even if all of this information is correct, the charges for specific items may seem unusually high. This might mean that there were adjustments to your insurance policy or that the insurance doesn’t cover the specific brand of treatment that you received. Always make sure that you read mail from your insurance company and stay up to date with policy changes so that you can prevent unwanted medical charges.

3. Communicate with your care providers and negotiate if you think it’s appropriate

When you receive a surprise medical bill it’s crucial that you get in touch with your insurer, doctor, and hospital (or other medical organization) as quickly as possible. Don’t procrastinate!

When speaking with your insurance company, ask for detailed information on each itemized charge on your bill. Make sure you clarify each of the following:

  • Deductible: Your deductible is the amount that you are required to pay for your medical services before your insurance will cover anything. If you have a high-deductible plan, it is possible that your insurance may not cover the services you received. Be sure that you have a full understanding of your deductible to avoid any surprise charges.
  • Copay: Your copay is the amount that you pay to supplement your insurance coverage. For example, if an annual physical costs $250 total, your insurance might cover $225 and require that you pay a $25 copay directly to your doctor’s office. Knowing what your copay is will help you decipher your medical bill and better understand any confusing charges.
  • Out-of-pocket Maximum: Your out-of-pocket maximum is exactly what it sounds like – the maximum amount that you will pay for any medical services under your plan (usually for that given year of coverage). Knowing your out-of-pocket maximum is particularly helpful when dealing with surprise medical bills because you can clearly demonstrate where you are being overcharged.

Your insurance company representative can walk you through each of these things and help you decipher whether you should be receiving more coverage than your bill reflects. You can also ask the insurance company to speak directly with your doctor or healthcare provider to negotiate a lower rate.

Also get in touch with your healthcare provider to ask whether they are able and willing to charge the typical market or in-network rate (i.e. to charge the amount that it would cost if they were in-network with your insurance plan). Be sure to ask:

  • Why you were charged for each specific service
  • Which items on your bill are negotiable: Some providers will offer a sliding scale for services if your insurance does not cover them or you do not have insurance. Make sure to inquire whether you qualify.
  • Whether your diagnosis codes were billed properly for full coverage: A diagnosis code tells the insurance company what you were being treated for and directs them to cover (or not cover) each service accordingly. If your provider mis-labeled the diagnosis code, it can make all of the difference. Make sure that any preventive services are labeled as such (as those are typically covered by insurance) and clarify all other codes with your provider to be safe.

Once you are clear on all of these factors, you can try step 4.

4. File an appeal with your insurance company

You can file a formal appeal with your insurance company to try and get them to cover more of the services billed. Medical bills typically provide instructions on how you can appeal the charges.

While you’re going through the appeal process, notify your doctor’s office so they know that you are disputing the bill. Ask them to avoid sending the bill to collections while you get it covered, but understand that doctors are not obligated to hold off on sending the bill to collections if its been too long.

The current healthcare system is confusing enough as it is, nevermind surprise bills and charges. If you do wind up with an unexpected charge there are certainly ways to appeal it. And know that if you are not successful in appealing you can always look into payment plans and/or financial aid.

Most PlushCare articles are reviewed by M.D.s, Ph.Ds, N.P.s, nutritionists and other healthcare professionals. Click here to learn more and meet some of the professionals behind our blog. The PlushCare blog, or any linked materials are not intended and should not be construed as medical advice, nor is the information a substitute for professional medical expertise or treatment. For more information click here.

Our commitment to you.

PlushCare is dedicated to providing you with accurate and trustworthy health information.

  • right Tick Image

    Research from sources you can trust

  • right Tick Image

    Medical reviews by field experts

  • right Tick Image

    Frequent content updates

More to learn.