4. Don’t pay until all bills are in. 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. You will generally owe only the “patient responsibility” amount indicated on those forms for in-network care.
5. Fight back against stealth out-of-network bills. 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. See our advice on managing your health-care bills.
6. For elective out-of-network care, find out about your plan’s reimbursement policy. That information should be in your health-plan documents, but if 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. Typically a plan will pay a portion, such as 60 percent, of that agreed-upon price. You’ll be obligated to pay the rest plus the balance of whatever your out-of-network provider decides to charge. So if a non-network doctor charges $2,000 for a treatment and the insurance company says the allowed price is $1,000, it will reimburse you $600 and you’ll owe the doctor $1,400.
7. Negotiate prices with the out-of-network provider in advance. Start by looking up the “fair” prices in your geographical area for your test, procedure, or operation on FairHealthConsumer.org, HealthcareBlueBook.com, or both. Fair Health also has a sliding tool that shows what your reimbursement will be if your plan pays a percentage of Medicare’s fee schedule for out-of-network services. Use those results as a basis for negotiating a price agreement with the out-of-network provider, and get it in writing. Healthcare Blue Book has a printable standard contract you can use for that purpose. Failure to agree on a price in advance could leave you liable for a very, very large balance bill.
8. For complex out-of-network procedures, prepare for lots of homework. If your procedure or surgery isn’t included on either HealthCareBlueBook.com or FairHealthConsumer.org, 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.“Call the insurance company with this information, and they are absolutely obligated to tell you what they will pay,” says Jennifer Jaff, executive director of the nonprofit group Advocacy for Patients with Chronic Illness. “This is not information they’re going to have at their fingertips. Chances are it’s going to take days.” Once you have that information, negotiate with your provider as above.