Medical Bill Basics

Medical Bill Basics

Medical Bill Basics – Avoiding surprise bills


Know the basic terms:

In-network provider:  A doctor, hospital or health-care facility that has an agreement or contract with your insurance company and provides services to plan members for negotiated rates.

Out-of-network provider:  A provider who is not affiliated with your insurance company.  In most cases, an insurance company will not pay for services received from an out-of-network provider.

Deductible:  The amount of money you have to pay out of pocket each calendar year before your insurance will start paying.  Generally, if you have a plan with co-pays, you do not have to pay the deductible first for visits with a co-pay although there are plans that are deductible first, then co-pays apply so know your policy well.

Co-pay:  A flat fee you pay to a health-service provider.

Co-insurance:  The percentage of charges you pay to the medical provider after your deductible has been met.  You pay this percentage until you reach your annual out of pocket maximum.


Ask your surgeon for a complete list of doctors and facilities that will be used.  Call your insurance company to discuss your plan and determine if those doctors and facilities are in-network.  If it is not possible to do your procedure completely in-network, contact the out-of-network providers and clarify the balance you will be responsible for so you can eliminate the surprise of a post-op bill.

If you get an unexpected bill, talk to your insurance company and the provider.  Some providers may accept the insurance payment as payment in full, or the insurer and the out-of-network provider may negotiate a fee and decrease the balance you owe.


Anytime your doctor writes you a prescription, find out how much the medication costs, whether it is covered by your insurance and if there is a low-cost generic alternative.

When selecting your insurance, check with the company to see if your current medications are covered.  You will get the lowest out-of-pocket costs when you buy the “preferred”, generic, or Tier 1 drugs.  A drug that isn’t listed will have the highest out-of-pocket cost and may not be covered by your insurance.

Insurance companies adjust their list of medications they cover at any time.  If you find out the medication you take is no longer covered, ask your doctor if you can take a generic or a similar drug covered by your plan.  If not, you can ask for an exception from your insurer.  You should also shop around for the best pharmacy price, and ask if the medicine’s manufacturer has any coupons.


Your emergency room treatment may not be treated as in-network, even if the ER is at an in-network hospital.  Find out which hospitals in your area employ in-network emergency providers.  If you get a surprise bill from an emergency room visit, contact your insurer and explain that since it was an emergency you did NOT have a choice of providers.  The insurance company may reprocess it as in-network.  If not, contact the provider and ask them to negotiate a reasonable fee.

For non-life-threatening situations, going to an urgent care is cheaper option than an emergency room.


“Balance billing” occurs when an out-of-network provider bills the patient for the difference between the amount they charge and the amount insurance paid.  If you are on the hook for the balance owed, contact the provider and try to negotiate a reasonable fee.

Before paying any bills, always double check the bill.  Compare the itemized bill to the explanation of benefits received by the insurance company to make sure you have been charged correctly and all credits have been applied.

As always, you can call our office for assistance.