Protect Yourself From Unexpected Medical Fees: Expert Advice on Keeping Surgery Costs in Check


by Ann Matturro Gault

Source: QualityHealth

Surgery can be scary. Not only are there risks associated with going under the knife, but recent news reports have called attention to another cause for concern: the large fees charged by out-of-network health care providers who have provided surgical assistance without a patient’s prior knowledge or approval. In one case, an out-of-network assistant surgeon was called on to help with a herniated disk procedure; the patient received a $117,000 bill from a doctor the patient had never met.

As health insurance coverage continues to evolve—and more costs shift to consumers—experts say consumers should be aware of these practices, become more informed about costs, and be prepared to do more to protect themselves. QualityHealth recently spoke to health economist Devon M. Herrick, PhD, a former hospital accounting manager and a senior fellow at the National Center for Policy Analysis (NCPA) about what you can do to minimize surprise bills and out-of- pocket expenses.

Q: How do surprise charges happen?

A: Physicians and other health care providers helping each other with patient care is nothing new. What’s new is patients and insurance companies being billed for services from health care professionals (both in and out of network) when the need for them may be questionable in some cases.

The doctor involved usually isn’t the primary care physician that the patient knows. More commonly, medical “gotchas” occur during procedures that involve non-emergency surgery, when the services of other physicians such as a radiologist or anesthesiologist may be required.

Of course, there are legitimate instances in medicine—when something unexpected happens during a routine procedure, for example—that require a doctor with expertise. No one disputes that keeping a patient alive is the main concern in a life-or-death situation; not bargain shopping for medical coverage. But consumers should know that out-of-network physicians typically charge 20 percent (or more) than the usual local rate, depending on where the service is performed.

Q: Is this a growing problem?

A: We’re living in a time when insurers are cutting back on reimbursement, and physicians and hospitals are looking to make up for lost revenue. Complicated billing codes, doctors with no incentive to save you money, and hospitals not concerned with consumerism all contribute to exorbitant prices. My research suggests that the problem of surprise bills seems mostly construed to the northeast, possibly due to market dynamics that are unique to that part of the country.

Q: How can patients protect themselves?

A: Be on guard, take an active role, and ask a lot of questions. Prior to elective (non-emergency) surgery, explain your concerns about unexpected charges to your physician. Find out who will be involved with the procedure, and whether or not these other doctors are in your health care network. You have the right to refuse anyone out of network.

Contractors once included in the daily hospital rate may now bill separately for services. Be sure to ask the hospital and doctor if there are vendors who commonly provide services in the normal course of surgeries—a pathologist, for example. If so, find out if these people are employed by the hospital or if they are contractors, so you can verify that they’re in network.

One other important tip: when the admissions clerk (or billing person in a doctor’s office) asks you to sign proof of financial responsibility, ask them to go over the forms with you. Let them know you don’t want any out-of-network "surprises."

If there is a blanket statement attesting to the fact you will pay anyone regardless of who they are, don’t sign it until it has been clearly explained to you. If the doctor or hospital doesn’t want to clearly explain who and what you are being asked to pay for, then you may want to find another doctor or facility.

Finally, it never hurts to talk with your insurance company or health plan. See if they are willing to pay out-of-network providers if the provider has agreed to accept in-network fees. And if an out-of-network provider is brought in due to an extenuating circumstance, ask that his office work with your insurance carrier to negotiate an out-of-network price.

Other Cost Saving Tips

Herrick also discusses other ways to make sure your bill isn’t a horrible surprise:

Ask for an itemized bill to align your care with what you paid. It’s wise to have a record of the procedure as well as labs and tests that were performed.

Speak up before the procedure. You can attempt to negotiate with the hospital once you receive a bill, but it’s generally easier to work out the price before the service is performed. Also know that "Hospital list prices mean nothing," according to Herrick. "Many of those prices are fictitious and few people actually pay them, but it’s a basis for negotiation."

Check your insurance company’s website for cost-saving information and incentives. Some companies reward consumers who do their part to keep charges reasonable. For instance, Cigna’s Informed Choice program will expedite the approval process and will even make appointments for members who choose treatment at certain facilities.

The Future

Currently, "Health care is the only market where consumers don’t comparison shop before making a big decision, the way you would before purchasing another big-ticket item like a home or a car," Herrick says. "At the National Center for Policy Analysis, we like to say that introducing competition is the only way to change health care. There’s a reason prices aren’t transparent at the hospital. But as long as doctors aren’t competing on price and patients aren’t price-sensitive, don’t expect change."

In the meantime, use the tools above to help ensure that healthcare costs don’t make you sick.

Devon Herrick, PhD, reviewed this article.