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Surprise medical bills can be expensive: Of the 1 in 5 Americans who received an unexpected bill within the last year, 22% were charged over $1,000, according to a 2022 survey published by business intelligence company Morning Consult.
While unexpected bills may not be completely avoidable — and your health insurance might not cover every last expense — there are questions you can ask medical providers to help you avoid paying more than you have to, and to clarify how much you’ll actually owe before undergoing a procedure or test.
Here are four questions to start with, from Todd Thames, a physician and VP of clinical affairs at Included Health, a virtual primary care provider that helps customers navigate medical bills.
1. What are my out-of-pocket costs?
Instead of asking, “Am I covered?” by your health insurance, ask both your health-care provider and insurer what your total out-of-pocket costs should be, before you get treatment.
“Coverage can mean very different things,” depending on the interpretation, says Thames. Being “covered” could include partial coverage, where you still have to pay a percentage of the total cost of the bill.
Just remember that when you ask for out-of-pocket costs, you might not get an estimate right away. That’s because a medical provider might not be familiar with the dozens of health insurance policies their patients have, including yours, says Thames.
“The doctor or the provider might say, ‘I don’t actually know that at the moment. But let me do some research or have my office manager do some research for you,'” Thames says.
Once you receive the estimate, you can run it by your insurer to confirm what’s actually covered, Thames says.
2. Is this procedure or test diagnostic or preventative?
Preventive care is when you exhibit no symptoms and have no reason to believe you might be unhealthy. Diagnostic care is when you have symptoms or risk factors that require a diagnosis from the doctor.
Most preventative care is covered by health insurance plans. However, diagnostic care is much more likely to incur out-of-pocket medical costs, says Thames.
While you might not be able to avoid charges for diagnostic care, you can use this question to confirm out-of-pocket costs while raising affordability concerns with your doctor, as they might be able to find ways to reduce the cost.
For example, sometimes doctors order a diagnostic lab test called a “comprehensive metabolic panel,” which measures up to 14 substances in your blood. “That tends to be a default test that gets ordered, even if only a couple tests are necessary,” says Thames. If you express cost concerns, the doctor might recommend a more targeted lab test that can reduce how much you owe in medical bills.
“It’s a fair question to say, ‘what is this lab test for and how is this going to impact my care?'” says Thames.
3. Is there a generic medication that works just as well?
In almost all cases, generic medications are less expensive than brand-name medications, says Thames. Simply asking for an alternative generic medication based on affordability concerns can influence what a doctor prescribes.
“One very common medicine that we use for patients with diabetes is a medicine called Metformin,” Thames says. “There’s different formulations: There’s Metformin that you can take a couple times a day, and then there’s an extended release version that’s more expensive.”
While doctors might typically prescribe the extended relief version out of convenience for the patient, they might not be thinking about the increased costs, he says.
“I’ve had patients where we say, ‘let’s just stay with the twice a day dose, because that’s much more affordable for you,'” says Thames.
Most doctors have a general sense of what medications might cost, so they could suggest an alternative on the spot, say Thames.
4. What is the CPT code for my procedure?
Another way to ward off unexpected medical charges is to confirm the “current procedural terminology” or “CPT code” for your procedure before it happens. CPT codes describe medical procedures and are used by insurers when processing claims.
This is a reasonable request you can make with your health-care provider, says Thames. Once you get the CPT code, you can run it by your insurer to confirm if they will cover the service.
“Third-party payers and insurance companies think in terms of billing codes as opposed to procedure names,” says Thames. “CPT language is confusing, but for any planned procedure, either the clinician or someone in the clinician’s office should be able to supply the codes needed.”
Disclosure: Comcast, the parent company of CNBC, is a client of Included Health.
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