How to Avoid Surprise Medical Bills

Allison Pahnke, BSN, RN, CCM, care manager at Network Health

Anytime you get a surprise bill, it’s frustrating. This is particularly true for medical bills, which can often be a big chunk of money, especially for urgent or emergency services.

If you’re currently staring at a large medical bill, you didn’t expect and asking yourself whether you could have saved money by doing something different, you’re in the right place. Whether the answer is yes or no, by the end of this article, you’ll have a better understanding of how care is billed and what you might be able to do to avoid future surprises.

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What You Need to Know About the No Surprises Act

The No Surprises Act is a federal law designed to protect patients from certain unexpected medical bills, especially in situations where you don’t have much control over who provides your care.

In simple terms, it helps prevents “balance billing,” which happens when an out-of-network provider bills you for the difference between what your health plan pays and what they charge.

Under the No Surprises Act, patients are generally protected when…

• You receive emergency care, even if it’s from an out-of-network provider
• You receive certain services from an out-of-network provider at an in-network hospital or facility.

In these situations, you typically pay only your in-network cost-sharing amount, while the provider and insurer work out payment differences behind the scenes. That said, the law doesn’t eliminate every possible surprise bill. For this reason, asking questions ahead of time and calling your health plan when something doesn’t look right is still important.

How to Anticipate and Avoid Unexpected Medical Bills

Budgeting for Deductibles

If your plan has a deductible, one option is to set aside money to cover your deductible each year. That way, if you do receive a bill that you didn’t expect, you have the money there to cover it. Health savings and health reimbursement accounts (HSA and HRA) can help, especially if your employer offers a match, so review your employer’s health care benefits to see if that’s something they provide. The nice thing about an HSA is that any money you have in there will remain in there if you don’t use it and may even be tax free.

Using the Right Site of Care

While budgeting may not be realistic for everyone, you can still be thoughtful about where you receive care. Doing so can save you a lot of money.

The emergency room is often the most expensive place to receive care.

That isn’t to say you should avoid the emergency room, if you have an emergent need such as chest pain, shortness of breath or something which cannot be managed by your primary doctor. It can be difficult to differentiate between what is considered emergency care and what is urgent care. It may not always be obvious which to use, but the bills for each can be very different amounts.

Here’s a good quick guide to help you out:

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MDLIVE for Virtual Care

MDLIVE offers a convenient, cost-effective way for Network Health members to connect with a board-certified doctor anytime day or night without leaving home. Whether you’re dealing with common conditions like colds, allergies or minor infections, MDLIVE allows you to receive care and even get prescriptions filled when your personal doctor isn’t available.

As a virtual care option, it can help you avoid the more time-consuming and expensive in-person visits. Plus, getting started is simple. You can register through your member portal, by text, through the MDLIVE mobile app or with help from our Member Experience team (just call the number on the back of your member ID card).

Understanding Preventive vs. Diagnostic Care

It can also be helpful to understand whether the care you’re receiving is considered preventive or diagnostic. The latter will almost certainly cost more.

Preventive means routine care with no symptoms to suggest something’s wrong.

Diagnostic means there are existing symptoms or follow-up testing is needed after preventive care.

For many forms of care, such as mammograms, colonoscopies or your annual wellness exam, the first time will usually be considered preventive if you don’t have any symptoms (though it’s always best to check your health plan coverage to be sure). Once something is discovered, however, diagnostic tests may be required that don’t fall under the preventive category.

When it comes to billing, the difference between preventive and diagnostic is in the billing code. You can ask the provider how it’s being billed if you’re unsure whether something is preventive or diagnostic.

How Prior Authorization Works

You may have heard this term “prior authorization,” and it’s just a fancy way of saying that your doctor needs to get the OK from your health plan to ensure a health care service is covered by that plan. This can sometimes be required for MRIs, CT scans, surgeries, hospital stays or certain medical equipment.

Here’s the problem. Sometimes these requests aren’t made until a week or less out from your care, whether that be a scan, a surgery or whatever else. This can cause scenarios where you show up to the hospital or clinic only for them to tell you that your health plan hasn’t agreed to cover your care yet, sticking you with the bill (at least until you can be reimbursed) or delaying your care.

Our suggestion? Check in with your provider ahead of time, as early as possible, to make sure they’ve sent the prior authorization request. It’s also helpful to call your health plan to make sure they’ve received it. Network Health offers a handy online portal where you can check your own authorization status, claims and estimation of benefits. This can be set up by going to Networkhealth.com and creating a log-in.

Ask About Medication Alternatives

Doctors will usually prescribe the medication that they think is best for your condition, but they don’t necessarily look at all options unless you ask. This means that cost and coverage aren’t always considered, unless you ask.

When being prescribed a new medication, ask your personal doctor or pharmacist to ensure it will be covered under your health plan and that the cost is affordable for you. Alternatives are likely to exist, whether it’s a different medication or a generic version of a brand name medication. People with employer or private health insurance are often eligible for medication coupons offered through the manufacturer, which can greatly reduce the out-of-pocket cost. Network Health also partners with Mark Cuban’s Cost-Plus Drugs, an in-network mail-order pharmacy offering hundreds of prescription medications at transparent discounted pricing. Members can request an exception if the prescribed medicine is not on your health plan’s formulary. Network Health has pharmacists on staff who may be able to help identify lower cost options as well. Considering all your options and asking questions ahead of time can ensure you’re not met with surprise costs when picking up your prescription.

How Network Health Can Help You Navigate Medical Bills

While we wish there were some miracles to make this entire process easier, it is unfortunately a limitation of the current health care system, and it needs some work. Network Health is here to help in any way we can, and we’ve seen just about every scenario you can imagine when it comes to medical billing.

Following our advice above can help you avoid any surprises when it comes to your medical bill. But if you have a bill that seems incorrect, always call us. That’s what we’re here for, and it never hurts to ask.