The Fineprint
How to Prepare for Appointments and Find the Lowest-Cost Plan
Table of Contents:
A clinic or hospital visit includes multiple healthcare providers, meaning multiple billers.
For instance, one simple emergency visit with an x-ray can include:
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Facility Bill (This covers the cost of using the x-ray room, the equipment used in the visit, and additional support from providers that are not the main physician.)
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Professional fee (This covers the radiologist who reviewed the x-ray and sent results to the doctor.)
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The Attending Physician’s Bill (This covers the office visit and evaluation.)
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Other Specialists’ Bills (If any other specialists were met, each professional would send their own separate bill for their services.)
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Each of these facilities or providers could have different network contracts, possibly resulting in the patient unknowingly being charged for out-of-network care. If possible, the patient should verify who is billing and specifically ask which groups are involved to ensure that each party is in-network for their plan.
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​Check out our How to Check if a Provider is In-Network Page!
Step 1: Verify that all providers and facilities are in-network
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Steps to Take Before the Visit:
Step 2: Confirm that there are no other alternative facilities that offer the same correct care but at lower costs.
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Moreover, different sites offer different costs. Before scheduling, the patient should know where their healthcare is being provided and whether another facility would offer lower costs for medically equivalent care. Hospitals often charge facility fees for covering overhead costs such as using equipment, maintaining the building, and non-physician staff members.
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Finding an alternative location to receive the same medical care can be vital in lowering costs and avoiding these facility fees.
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Alternatives to consider (if not a life-threatening or emergency situation):
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An outpatient clinic, imaging, or surgery center could lower costs
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A walk-in urgent care clinic
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Telehealth or virtual visits
Step 3: Ensure that there will be no penalties for mishandled paperwork.
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Administrative approval could also affect whether or not coverage is applied to medical expenses as many insurance services necessitate requirements such as referrals, specific timing, or provider names. Failure to meet these requirements often results in the insurance rejecting coverage after the service is performed. To prevent this, the patient should:
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Confirm whether prior authorization or a referral is required
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Verify who must submit the paperwork
Step 4: Request a cost estimate in writing.
In order to increase transparency, hospitals are required to provide clear pricing information online. This enables individuals to “shop” for the most affordable healthcare service or provider and select the best value.
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The No Surprises Act ensures that healthcare facilities and providers offer uninsured or self-pay individuals an estimate for the price of their healthcare treatment when requested, also known as the good faith estimate. If the patient is billed at least $400 above the good faith estimate, they can dispute the bill by the patient-provider dispute resolution (PPDR) process, initiated by issuing a request to HHS.
Steps to Take After the Visit:
Step 1: If insured, compare the EOB to the bill
An explanation of benefits does not constitute a bill, but it displays the total expenses of a visit. It explains how much coverage you will receive and what you will pay out of pocket when your bill arrives. However, discrepancies between an EOB and the actual bill issued by the medical provider are common. When this occurs:
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Collect all paperwork as, in some cases, multiple EOBs apply to one bill
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Ensure that the codes and descriptions of services outlined in the EOB match with the medical bill and check for duplicate charges
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Evaluate the services and ensure that only the services you were provided with are listed
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Ensure that the amount required to pay out of pocket aligns with your health insurance plan
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Ensure that the name and policy number are yours
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Contact the office or facility in which you received the services and request that they review the bill. If there was an error, inquire about correcting the bill
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Request an itemized bill and review for discrepancies between it and your EOB
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Call your insurance company and ask about the dissimilarities between the EOB and the bill
Step 2: Request an itemized bill
An itemized bill allows an individual to physically see what specific services went into the total expenses of a hospital visit. Hospitals are required to send out itemized bills upon request within 30 days.
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Though some hospital bills may seem similar to an itemized bill, a true itemized bill contains:
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Procedure identifiers known as CPTS or HCPCS codes that break down your fees
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Each service listed separately, typically with the dates of service, a description of what was done, and a charge for each item
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Provider details
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Gross charges, the hospital’s full price with no insurance adjustments
The breakdown of such information enables a patient to negotiate fees and identify if there were errors, such as:
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Duplicate charges
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Charges for services never received
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Charges for services that were not medically required
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Unbundling, or improperly billing a single procedure as multiple, smaller procedures
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Upcoding, or when a provider inflates the price of a basic service by using a code for a more advanced version