If gas stations worked like health care, you wouldn’t find out until the pump switched off whether you were paying $3 or $30 a gallon, notes Consumer Reports. If clothes shopping worked like health care, you might pay $80 for a pair of jeans at your local boutique and $400 for the identical pair at the nearest department store — and the clothes wouldn’t have price tags on them.
The reason is that neither providers nor health insurers really want consumers to have information about costs. Here’s why: The contracted prices that health plans negotiate with providers in their networks have little or nothing to do with the actual quality of services provided and everything to do with the relative bargaining power of the providers.
Here’s CR’s advice on how to avoid unwelcome surprises:
Okay, it’s not a fun read, but it pays to familiarize yourself with the rules and cost-sharing features of your health plan. How much is the deductible? What out-of-pocket costs apply toward it? Is there an extra co-pay for the emergency room?
Network providers have agreed to accept the negotiated health-plan price as payment in full. Even if you haven’t met your annual deductible, you’ll pay the in-network price, and if you have met it, you’ll only be on the hook for your co-pay or coinsurance.
Many health plans post some price information online. Take advantage if you can. If you can’t, call your plan’s customer-service number. If that fails, call providers directly, but be aware that some of them truly might not know your network’s price.
You may receive a hospital bill with scary-looking high “charges” on it. Don’t panic, and don’t write a check. They’re list prices, typically much higher than the network price you’ll actually owe. Save all provider bills and compare them with the explanation of benefit (EOB) forms that you’ll eventually get from your health plan. According to CR, you will generally owe only the “patient responsibility” amount indicated on those forms for in-network care.
If you get blindsided by a bill from a non-network doctor after surgery or an emergency-room visit in a network hospital, you might be able to get it reduced if you make enough noise. First, ask the doctor to discount the fee. If that fails, complain to the hospital, your insurer, your employer (especially if you work for a large company) and your state insurance department or state health insurance consumer advocate.
That information should be in your health-plan documents; if it’s not, call the plan and ask. Some set their own “allowed amount,” some use the Fair Health pricing database and some pay a set percentage of Medicare’s fee schedule.
Negotiate prices with the out-of-network provider in advance. Start by looking up prices in your geographical area for your test, procedure or operation at www.fairhealthconsumer.org, www.healthcarebluebook.com or both. Fair Health also has a tool that shows what your reimbursement will be if your plan pays a percentage of Medicare’s fee schedule for out-of-network services. CR recommends using those results as a basis for negotiating a price agreement with the out-of-network provider, and getting it in writing.
For complex out-of-network procedures, prepare for lots of homework. If your procedure or surgery isn’t included on either of the sites mentioned above, ask the out-of-network provider for the CPT codes (standard medical billing codes) for each service to be performed. Also get the provider’s tax identification number and the Zip code of the location where the service will be performed. Once you have that information, negotiate with your provider as above.