Sticker Shock: How to Avoid Surprise Medical Bills
May 30th 2019

Sticker Shock: How to Avoid Surprise Medical Bills

It's hard enough to recover from an illness or surgery without being hit with surprise medical bills. That type of unhappy surprise is a very real concern for many people. According to the April 2019 Health Tracking Poll from the Kaiser Family Foundation (KFF), unexpected medical bills are a major concern for half of all Americans. In addition, previous KFF polling found that two-thirds of Americans worry about being able to afford an unexpected medical bill, and three-fourths of the public want the federal government to step in and take action to protect patients from having to bear costs resulting from certain types of out-of-network care.

Meanwhile, it may help to think proactively about what you can do to minimize your chances of receiving a medical bill that raises your eyebrows. The SmartChoice program administered by eviCore on behalf of your health insurance plan may help you understand cost differences and options for your care. Your plan may also offer additional tools to help you navigate through healthcare costs. Call the number on the back of your insurance card if you have more questions about these options.

Here are some steps you can take to reduce the chances of having to pay a surprise medical bill:

Learn What Leads to Surprise Medical Bills

First, let's take a look at what a surprise medical bill really is. While there are multiple culprits potentially responsible for that unwanted envelope in your mailbox, here are three typical scenarios that result in a surprise bill, according to the American Hospital Association:

  • You tried to get care from a doctor considered in-network by your healthcare plan, but you unintentionally received care from an out-of-network doctor in an in-network hospital.
  • You received emergency care, but your health plan decided it was unnecessary and denied payment.
  • You received emergency care from out-of-network providers who weren't covered by your health plan.

Understand Your Health Plan

To maximize your chances of avoiding surprise medical bills, it's important to understand how your health plan works and what it covers. Do you know:

  • Whether your health plan covers 100 percent of preventive care costs? If not, find out what's not covered.
  • What specific preventive services are covered by your plan? You might get hit with additional fees for certain services because your plan doesn't actually consider them to be preventive, like a diagnostic mammogram instead of a screening mammogram.
  • What your out-of-pocket maximum is? Usually, once you spend a certain amount, you won't be responsible for any more cost-sharing—unless you see a provider who's considered out-of-network. Then you may still owe money.
  • What kind of coverage for screening tests your plan provides?

If you don't know the answers to those questions, you might be unintentionally putting yourself at risk for accessing care that your plan might not cover. However, you can always call the number on the back of your card and ask your health insurance company to provide the billing codes for the medical services and tests that they do cover. Then, when you visit your provider, ask which services you'll be receiving. That will allow you to compare the billing codes and make sure they match up with the ones listed as covered by your health insurance.

Learn How to Schedule Care in Advance

It's easier to avoid surprise medical bills when you schedule a procedure or other type of care in advance. You can check with your health plan's directory, which may provide answers many of your questions about what your plan covers. And if you can't find what you're looking for, call your health insurance plan and ask questions such as:

  • What providers are in my plan's network?
  • How does my plan cover care from a provider who's not in-network?
  • At which facilities can I receive the care so I can be sure that it will be covered?
  • What costs will my plan cover if I need to see a specialist?
  • Under my plan, do I need to get a referral from my primary care physician to get coverage of these services?
  • Who else providing care will be covered by my plan (e.g., anesthesiologists, nurses, etc.)?

Depending on the answers, you'll come away with a better sense of what will be covered and what won't be—and what you might have to pay for.

Don't just assume that everything will be in-network, though, if your doctor is in-network. Your doctor might order a lab test, but that doesn't guarantee that an in-network lab will run the test. It may be a good idea to shop around when you can. If you request a billing code for a particular procedure, you can use an online resource like to compare prices at various facilities in your area.

Plan for an Emergency Situation

You may find yourself in an emergency situation where you or a member of your family requires immediate care. You may not have time to research providers who are in-network or call around to find out which facilities offer the most cost-effective services. You can't always choose where you get that care.

For example, it may be worth your time to do some homework about ambulance providers in your area. Find out which ambulance providers are in-network for your plan and which aren't. Write the information down and keep it in an easily accessible area.

Next, make a list of preferred emergency departments nearby. Call your health insurance company to verify which ones are covered by your plan. Caution: the hospital and the emergency department may not be run by the same organization. Also call the emergency room billing department to see if they employ their own physicians, and ask of those doctors are also in-network. Use this information the next time you find yourself in an emergency situation.

Don't Just Assume the Bill is Right

Finally, at some point, even with all your planning, you may still get a bill. Don't panic. But when the bill arrives in the mail, don’t automatically take that total cost at face value. There are some steps you can take to possibly lower the amount you owe out of pocket.

Look for possible errors such as a double charge for a particular service, incorrect information about your physician, or the date you received care, and so on. Your doctor's office may have miscoded the type of care you received, too.

Bottom line: if you're not certain the amount is correct, question it. Call your health insurance plan at the number on the back of your member card and ask. The bill may be incorrect, in which case you can request an updated version.