Patient Guidelines: Managing Medical Costs

Last Revision: 03/26/2021

No matter if you’re rich or poor, the cost of quality health care should not lead to personal decisions that put your health at risk. In most cases help is available.

Start Lowering Costs by…

Talking with your doctor about your financial goals as soon as possible.
Understanding your health insurance coverage and benefits.
Shopping for non-emergency services.
Learning how to access free and low cost care in your community.
Negotiating fees and payments with providers.
Checking medical bills for errors. They happen 80% of the time.
Applying for free/charitable care when appropriate.
Understanding medical fundraising services.

Quick Tips

1. Diagnostic tests like a MRI or blood test are less expensive at independent facilities than in hospital settings.

2. Stand-alone imaging centers, outpatient surgery centers, urgent care clinics, and walk-in clinics are generally much less expensive than hospitals. Find out which ones close to your home are in your insurance network.

3. When you have a choice of location, outpatient treatment is typically lower cost that inpatient treatment, with equal or better quality.

In this article you’ll learn to…

Find free help for any health care issue.
Find financial help.
Work with your doctors to lower your costs.
Lower your medical bills.
Find mistakes in your medical bills.
Negotiate lower prices for non-emergency services.
Negotiate no interest payments terms.
Access free health care.
Manage your health insurance costs.
Shop for non-emergency health care services.
Manage your healthcare finances.
Raise money for health care expenses.
Understand medical tourism.
Compare prices and quality of health care services.

Finding Help

There are a wide variety of financial resources and assistance programs available to patients in need. Some are illness related. Others are not.

Most assistance programs target children, elderly, cancer patients, patients suffering from a life-threatening illnesses and chronic conditions, and patients who are financially challenged. Funds are typically available for basic living expenses, child care, medical equipment, supplies, medical bills, housing, general health care, dental care, vacations, special wishes, and travel for treatment.

The primary sources of direct financial help are;

Health Insurance
Government Programs
Public and Nonprofit Hospitals
Co-pay Relief Programs
Patient Assistance Programs
Assistance from Voluntary Organizations
Fundraising
Personal Financial Planning

Quick Tip

4. The list below is just a few of the hundreds of sources of financial help.

aPatientsPlace.com: Categorized index of financial assistance programs and health care resources with contacts and phone numbers.
CancerCare: Source of financial assistance for cancer patients and their families.
GiveForward & GoFundMe: A tool for raising money for health care expenses.
PatientResource: Offers financial resources & prescription drug help at;
GovBenefits and BenefitsCheckUp: If you want to know if you qualify for Medicaid, or if you’re a senior needing help paying for prescription drugs, health care, and other health services, or you want to know what government assistance programs you qualify for at both a Federal and State level. The organizations represented have helped more than 2 million people and provided almost $8 billion dollars in annual benefits.
Health Resources and Services Administration (HRSA) Information Center: The HRSA information center provides publications, resources and referrals on health care services for low-income, uninsured individuals and those with special health care needs via their web site at ask.hrsa.gov/, or through their toll-free number; 1-888-Ask-HRSA. Users will find detailed listings of facilities that provide free or reduced-cost health services, information on sites that provide comprehensive primary health care services for people living with HIV, listings of dental providers who provide care to people living with HIV, organ donor cards, etc.

It often takes a combination of resources to get the help you need. Resources come and go every day and options are in a constant state of change.

Your Doctor(s)

The time for accepting anything less than a partnership from your doctors and medical providers is over. Doctors, hospitals, and other health care providers are beginning to receive reimbursement from Medicare and insurance payers based on their ability to provide and coordinate quality care. Your participation as an active member of your health care team is critical if your providers are going to get the best results.

Very few people tell their doctor and health care providers that they are trying to keep their health care costs down. If you do this as soon as there is an opportunity it can open a discussion about how your doctor might help.

Here are the steps to having the conversation…

Explain your situation.
Tell your doctor that you are trying to keep your medical costs down.
Ask if the doctor and the practice can help you identify ways to accomplish this by having a needed test or procedure can be done in an outpatient surgery center instead of the hospital, getting a generic drug instead of a prescription medication, or if there are alternatives to high cost procedures, drugs, or treatments.

Quick Tips

5. When doctors write a requisition for a test or procedure you can usually fill it at any facility or pharmacy. Shop around.

6. The most important thing to do is ask questions about everything.

Examples of questions you might ask include;

Why is this test necessary?
Are there lower cost alternatives to this treatment?
Is there a generic version of this medication?
How much will that cost?
How much of the cost does my insurance cover?

The Agency for Health Care Research and Quality says that talking with your doctor and health care providers leads to better results, higher quality, and more satisfaction. If your doctor in annoyed by your questions or doesn’t seem interested in helping, work with your insurance provider to find a new doctor.

Your Health Insurance

If you have health insurance they are a primary payer for the health care services you consume. Knowing your policy’s benefits and rules is crucial to lowering your medical costs.

Learn your benefits by…

Contacting your insurance provider.
Getting a copy of your health insurance policy and reviewing it.
Asking your provider to explain anything that you are uncertain about.
Asking for suggestions to lower your medical costs based on your past and anticipated expenses.

Every health insurance plan has its rules and requirements. Unfortunately, they’re often buried on a web site, or in print literature mailed to you along with several hundred pages of information. Make sure you know and follow them. Failing to do so can increase your costs. For example, your doctor gives you a prescription before you leave a hospital after surgery. Once you fill the prescription you discover that your plan won’t cover it because it was written in the hospital — but would have been covered it if it had been written in your doctor’s office.

Quick Tips

7. Annual Preventive Checkups are one of the few services that most insurance providers now cover.

8. Contact your health insurance provider, and ask for a list of the preventive tests and screenings that are 100% covered by your insurance.

9. Know Your Health Insurance Plan’s Rules; contact your health insurance provider and ask where you can find their “rules and requirements.”

10. Ask your primary doctor about having medications on hand for common complications.

Fighting Coverage Denials

Health insurance companies are known to deny claims because they know there is a good chance the consumer will not appeal. If your insurance company won’t pay for a service you think you deserve don’t just give up. Appeal the decision.

How do you know if your claim is denied?

An Explanation of Benefits (EOB) which is sent by your insurance company to you is one of the only ways to determine what the insurance paid to the provider and how much you may still owe. The EOB should also disclose if your claim has been denied.

If the insurance company portion of the payment shows $0, this can indicate a denial. The payment amount should be followed by a “Reason Code.” This code provides an explanation for the lack of payment. The insurance company may also send you a letter confirming the denied medical claim and detailing their reason(s) for denial.

Make sure to keep copies of all correspondence you receive from the insurance company, including denial letters, approval letters, your health history, medical files, doctor’s letters, etc.

Quick Tip

11. Keep a written record of all contact and phone calls with the insurance company; including the name(s) of the people that you spoke too.

If your insurance company denies coverage follow the steps below:

Step 1

Check your plan to make sure the benefit you want is included. Make a note of the part of the policy that leads you to believe your claim should not have been denied.

Step 2

Collect and organize all information pertaining to the denied claim. Make sure you have the original bill with the date of service and the provider’s name, your EOB, and your insurance card before placing a call. If the insurance company sent you a letter have that available as well.

Step 3

Call the number provided on the letter from your insurance company, or if you did not receive a letter call the customer service number. There is a possibility the claim was denied because of missing information. Once the missing information is provided the claim will be re-processed and hopefully you are done.

Step 4

Sometimes claims are denied because of miscoding. If that’s the case, ask your doctor to review the coding and re-submit a request with more specific medical justification for the procedure or medication and you should be done.

Step 5

If your claim was not denied for missing information or miscoding, find out why it was denied and how you can file an appeal.

Step 6

Ask the insurance provider’s representative for written guidelines for appealing denials.

Step 7

Make sure you have the address for the appropriate department to return the completed appeal documents.

Step 8

Always keep a record of the date, time, and the name of the insurance provider representative you talked with, along with a summary of the discussion. Keep this with copies of any documents you send to the insurance company.

Step 9

When appealing a denied claim you should have the opportunity to review the information the insurance company used to make their decision.

Step 10

If necessary get your doctor involved. Their office should have staff that can help explain why the procedure or care was needed or medically necessary.

Step 11

Get help wording your appeal(s) so that they mention medical problems and do not include words that automatically trigger denials. Talk to the person who handles insurance claims at your doctor’s office. This person may be able to help you with the appeal process, and they may provide any documentation your insurance company requires.

Step 12

Each insurance company has its own appeal process. Before submitting your information make sure you have completed and included the required paperwork. Once the documents are complete keep a copy of everything for your personal records.

Step 13

Continue to go through all levels of appeal. The insurance company expects you to give up at some point.

Step 14

If your insurance company denies the claim again a second time in most cases you can contact them to request an external appeal. Usually, this appeal will be conducted by a medical professional or group of medical professionals not associated with the insurance company.

Step 15

Sometimes it takes the threat of a lawsuit to get your insurance company to move.

Quick Tip

12. Send correspondence to the insurance company via certified mail with return receipt.

Be persistent. Remember that a denial is often not the final word. Request in writing that your insurance company reconsider their decision. Contact your health insurance company within a reasonable amount of time if you don’t receive a written response that includes a justification.

If your appeal is denied again, and you believe that this is not consistent with your policy, contact your state insurance commission. That agency can mediate a dispute between you and your insurance company. If you win you could save yourself hundreds or even thousands of dollars.

Managing Surprise and High Cost Medical Bills

Surprise and high cost medical bills are the result of our broken healthcare system. Unfortunately, dealing with the stress of medical bills can be even more harmful than an illness itself, and it can have a devastating impact on your recovery and your family’s well-being. Fortunately, there are ways to manage and lower your medical bills to reduce and eliminate that stress.

Key steps for taking control of your health care finances:

Get copies and review itemized medical bills.
Let any creditors know about your financial situation.
Understand your income, expenses, health insurance, and financial resources.
Learn your rights and benefits under the law.
Make use of available resources; including financial help and no interest payment plans.
Get agreements in writing.
Keep your medical records and financial information organized so you can access it whenever you need it.

Quick Tips

13. If you have health insurance, your lowest cost is likely to come from using services in your “Provider Network.” That’s not enough though to get you the best price. Even the providers covered in your network are likely to charge different rates for a similar service.

14. Generic medications are typically far less expensive than brand name medications.

15. When you negotiate large bills with hospital or provider billing departments your first offer should be to pay a very small percent of your hospital bill in cash, quickly. When this is refused, (which it likely will be), ask to speak to the Billing Manager or the VP of Finance, and tell your story to them.

Start by Getting an Itemized Bill

More than likely, you will get a bill summary or an Explanation of Benefits from your health insurance provider as your first financial information. This is not good enough. Call your doctor, hospital, or provider, and request a copy of your itemized bill, including all charges.

An itemized bill will not usually be sent to you unless you request one. You can get a copy by calling the billing department of whoever sent you the bill and requesting a copy of your itemized medical bill, including all charges. Also ask for a copy of your medical chart and pharmacy ledger. Comparing these documents to your itemized bill will tell you if there are any charges for services that were not received.

Quick Tip

16. Look for charges that may have been added due to the provider’s errors. You should not have to pay for your provider’s mistakes.

Find Mistakes

One key strategy for lowering your medical bills is to make sure that all information and charges on your itemized bill are accurate. It’s estimated that as many as 80% of all medical bills contain errors. So, it’s well worth your while to review each bill.

You have two choices.

1. Review your medical bills yourself

2. Have a professional medical bill review and negotiation service do it for you for free.

Regardless of which method you choose, you will need an itemized bill that includes everything that you are being charged for. Patients are usually sent a summary of their hospital and/or medical bill from there provider, not an itemized bill. Each procedure or service performed by a health care professional has a code attached to it that allows a provider to bill an insurance payer. The code is called a CPT code, which stands for Current Procedural Terminology. That code is used to calculate the payment to the provider. Common errors include billing for things that were not provided, duplicate billing, and miscoding of services.

You or someone that you hire or trust should begin by looking for errors in service dates, data entry errors, duplicate entries, up-coding, bundling, and services that were not provided or needed.

Using a Professional Medical Billing Advocate

There are local and national medical billing advocates who will review your medical bills, find any mistakes, and negotiate lower fees without any out-of-pocket payment by you.

You send them a copy of your itemized bill(s) and they will take it from there. Medical bill review companies are usually paid a percent of what they save; often around 25% to 35%. They may also give you an option to pay hourly. This option is best used when you have a medical bill more than $10,000.

Here are a few leading medical bill review companies:

Copatient: (855) 505-1342:
Medical Bill Gurus: (800) 674-7836
Medical Cost Advocate: (201) 891-8989

Check Your Medical Bill Yourself

To check the accuracy of your medical bills you will need the itemized bill discussed earlier, and knowledge of medical billing. Here’s how…

Step 1

Compare your itemized bill to the “Explanation of Benefits” (EOB) statement that you received from your insurance company. In most cases, your insurance provider will send you an EOB. It will say, “This is not a bill.” The EOB will tell you how much the hospital is charging, what your insurance will pay, and what you owe. Review the EOB, and file it until all charges for all of the services you received have been paid.

Most itemized medical bills will include the following:

Account number
Services and/or procedures received
CPT and/or HCPCS codes may or may not be included
Services dates
Charges for each service
Insurance payments received
Amount owed to service provider

Due Date

There are several different codes that may be listed on your itemized bill. HCPCS Level I and CPT codes are universally used by all U.S. providers. They are often listed as the “service codes.” HCPCS Level II codes identify supplies or products used during your visit. These codes often start with a letter rather than a number, they might also be listed as service codes. ICD-10 codes are from part of a system that identifies possible diagnosis from the International Classification of Diseases. Every billed service with a CPT code must be linked to an ICD-10 code.

Here are a few sources to help you understand these codes:

Any medical dictionary
An HCPCS and CPT code sets.
An ICD code reference.

Step 2

Make sure that you received the services you were billed for.

Step 3

Contact your provider’s billing department for an explanation of any charge you do not understand.

Step 4

Make sure that no services were billed twice

Quick Tip

17. Get professional help if you don’t understand your itemized bill.

Unexpected Bills from Balance Billing

Balance billing is the practice of a health care provider billing a patient for the difference between what the patient’s health insurance reimburses and what the provider charges.

For most Americans health care is delivered through a network of providers who have agreed to accept the insurance plan’s reimbursement as payment-in-full. When patients receive care from out of their network these protections do not apply. Most often this happens during emergencies when a health care provider who is not part of your insurance network works at a hospital that is in your network.

When seeking emergency or elective care people must be aware that the doctors and other providers at the treatment facility may not be contracted by your insurance plan, even when the facility is “in network.”

In the case of emergency care, this can happen without the patient’s consent, or awareness. This is because hospitals contract with medical providers that do not accept the same insurance as the hospital. This is most common with physicians, anesthesiologists, radiologists, and surgeons. Depending on your insurance plan, your insurance company may not cover any of the out-of-network provider’s bill. This means that the doctor or provider is not bound by any agreement, and is free to send you a bill for the balance of their charges.

Quick Tip

18. Physicians and providers participating in Medicare may not use balance billing for any amount beyond Medicare’s standard reimbursement rate, or in some cases more than 115% of the Medicare fee schedule.

When you get a balance bill, call your insurance provider and your doctor. Find out if you have received a balance bill by a provider in your insurance network. If so you may not need to pay the bill.

If your bill is from a recent emergency check with your state’s insurance regulator. There may be laws that protect you against having to pay a balance bill. Here’s the link to a list of state insurance regulators from the National Association of Insurance Commissioners: http://www.insurance.naic.org/state_web_map.htm.

Unfortunately, privately insured Americans have only limited protection from balance billing in emergency situations, and no protection from balance billing from non-emergency services unless state laws have been enacted. Some states have recently passed laws protecting patients from balance billing. New York, New Jersey, Connecticut, Maryland, and Colorado all have some state laws. However, most of them have shortcomings that allow providers to continue balance billing.

Quick Tip

19. Help with a balance bill is available from Consumers Union at https://consumersunion.org/insurance-complaint-tool/

Also, call your health insurance provider and ask for someone to review and explain your bill(s) to you. They do not want to pay for overcharges any more than you do. Consulting with someone there can also help you understand how to dispute any extra charges. Even medical billing and coding experts are sometimes confused by charges that appear on hospital bills.

It is also possible that your doctor may be in your network, and the facility s/he operates at is not. This can leave you with expensive “facility” charges not covered by your insurance. This is one example when working with your doctor before your hospital stay to find a treatment facility in your insurance network can greatly reduce your medical bill(s).

Up-coding

“Up-coding” is another the practice that can cost patients money. This is the practice of a hospital, doctor, or health care provider billing an insurance payer using a code for a more expensive service than what was performed. This is fraud. Not only is it illegal. It also places inaccurate information on your medical record. Unfortunately, it happens.

Unbundling

There is also a practice called “unbundling” that you should be aware of. Medicare, Medicaid, and health insurance companies often have lower payment rates for groups of procedures that are often performed together. Unbundling those procedures and billing the services independently to get higher reimbursements is illegal. It is difficult if not impossible for the average consumer to know what payments are bundled. If you have a lot of medical bills it may be well worth your while to have a professional medical bill review. If you are dealing with bills of under a few thousand dollars it may not be worth your time to investigate this aspect of medical billing mistakes.

Negotiating Costs

When you are confident that your medical bill(s) are accurate, you can research the costs versus the fair prices of each line item on the itemized bill and then negotiate with your provider.

After You’ve Received a Bill

If you are overwhelmed by your medical bills, understand that you can almost always negotiate discounts or payment terms that will work within your financial situation. This applies even if you are unemployed or completely broke. Almost all health service providers will work with you if you work faithfully with them.

Working with your health service provider means agreeing to paying a part of the bill immediately in exchange for a discount, paying a small part of the bill each month, or applying for charitable care. The bottom line is that medical bills are negotiable. Many providers are happy to offer discounts to get charges off their books, and to avoid lengthy and sometimes costly collection efforts. To do so, they are often willing to take much less than their retail price. You will probably need to pay off your charges within 30 days, or set up an auto-pay by checking account to be eligible for any discount at most institutions.

Quick Tips

20. Call the doctor’s or provider’s billing department before the bill is delinquent. They will be much more likely to work with you then if you wait.

21. Do not offer to pay a medical bill with your credit card until the provider has agreed to a discount in writing. Health care providers don’t like credit cards as much as cash or checks because the fees that they pay the credit card companies can be quite high. Once providers have your credit card information they are much less motivated to negotiate rates.

To negotiate a discount follow these steps…

Step 1

Make sure that you have all your information regarding the accuracy of the itemized bill, the average or approximate medical costs, and Medicare Fee Schedule rates.

Step 2

Contact the provider’s billing department, and ask to speak with someone authorized to discuss and negotiate your bill.

Step 3

Once you are speaking with an authorized billing manager explain that you would like to discuss your bill and the repayment terms. If you found any errors in your bill, review them with the provider first. If adjustments need to be made make sure that those are completed and agreed upon along with the amount owed before discussing and discounts.

Step 4

Once the amount owed is agreed upon mention to the billing manager that the amount is much higher than you expected or can afford, and ask if they can offer any discounts if you can pay the entire balance quickly.

Quick Tip

22. Do not discuss discounts before you have agreed on the exact amount owed.

It is very common for providers to offer a 10% to 20% discount in exchange for payment in full within a few weeks. If you are offered a small discount respond by thanking them for their consideration, reminding them of your financial challenges, and asking them if they can offer you a bigger discount if you were able to pay them in cash, or with a guaranteed check within 10 days.

No matter what their response continue with the following steps…

Step 5

Thank them for their help.

Step 6

Ask them if they can send you an email confirming their discount offer.

Step 7

Ask them if it would be OK if you talked again tomorrow or the next day after you see if you can raise the amount due in cash.

Before you speak with them again compare their discount offer with the fair prices you found during your research.

Step 8

Call back within a day or two. Explain that you have some more information that you would like to discuss, and ask to schedule time to meet in person. If they will not meet in person ask if they have time to talk now, or if they prefer to schedule time to talk within the next few days.

Whether you meet in person or speak via phone be prepared to show them the fair price that you found through research, and ask them if they would accept that amount as payment in full.

Quick Tips

23. Don’t hesitate to ask to speak with a higher level manager or the person’s supervisor if you can’t get the bill reduced to something you are satisfied with. As noted earlier, get the agreed upon fee and terms in writing.

24. Get any agreement in writing before making a payment.

Negotiating Before Receiving Services

There are many research studies and articles that show how fees for the same treatment or test have a huge variation, even in the same area and from the same provider. If your treatment and care is not due to an emergency you’ll save a lot of money by being a good shopper.

It may seem strange to shop for the best price for a MRI or even where to deliver your baby. However, if you want to save money and your treatment and care is not due to an emergency you need to be a good shopper. There are many research studies and articles that show how fees for the same treatment or test have a huge price variation, even in the same area and from the same provider.

The cost for the same (in-network) procedures can vary by more than 400%. A CT scan of the brain costs $75 at a facility in Massachusetts, or $4,600 in Washington. The problem is that these same ridiculous pricing variations exist in virtually every community. A recent analysis from Castlight Health, Inc. showed that prices for a basic cholesterol panel test ranged from $15 to $343 for the exact same test within the same Metro area. The point is that a little shopping and a short drive could save hundreds of dollars on some of the most basic tests.

Here’s how to price shop:

Step 1: Learn the Specific Service(s) You Need

Ask your doctor to send you a list of the tests, procedures, and treatments that are recommended for you.

Step 2: Get the Billing Codes

Ask your doctor’s office or provider for the CPT codes for each service needed. You can also look them up yourself at the American Medical Association website, and learn what Medicare reimburses for each test or procedure. The codes are called CPT or DRG codes. CPT codes are for doctor’s office visits, and DRG codes are for hospital treatments. The more specific you can be the easier it is for a provider to give you a price, and you to look up competitive prices online.

Step 3: Research Service Providers

If you have health insurance you’ll save money by staying within your health insurance provider’s network. Start by investigating prices, experience, and quality of the doctors, practices, hospitals, surgery centers, and providers in your network.

Step 4: Learn the Fair Rate or Price for Each Service

It’s worth the effort to find out what the fair price is for each service that your doctor recommends. With a little work, you can find accurate prices for most services. There are several reputable, online resource for this information. A few of the more well-known health care price comparison resources are;

HealthcareBluebook.com – provides users with a “fair price” based on a database of rates paid by private insurers. FairHealthconsumer.org – provides an easy to use dental and medical cost estimator tool. NewChoiceHealth.com – provides list prices based on Medicare data in your local area. One of the largest out-of-pocket expenses is for imaging procedures like CT scans, ultrasound, and X-rays. Another big expense can be prescription drugs. The website SaveOnMedical.com lets you shop for different radiology, prescription drugs, surgeries and lab tests.

More and more states have cost comparison sites. Go to your State Department of Health web site to find out whether your state offers cost comparisons. These sites give prices for specific procedures at specific facilities. You can find websites and contact information for every State or Territorial Health Department.

Step 5: Find Out How Much is Covered by Your Health Insurance

Find out how much your insurance pays the service provider for both in-network and out-of-network providers. Call your health insurance customer service number, share your list with them, and ask them how much of the costs you will be responsible for paying for each service.

Step 6: Using the billing codes from Step 2, ask for an Estimate of the Charges for the Service Provider

Quick Tip

25. You must ask for an estimate that includes the associated charges.

You can accomplish this by calling the billing departments of your doctor, and any recommended providers. Get the name(s) of the people that you speak with. The prices that they quote you will likely be their retail or top price. Remember, insurance companies and Medicare pay providers much less than their retail price. You will likely be able to negotiate a lower rate.

Step 7: Find out How Much You Will Need to Pay

If you have health insurance call them and find out how much of the cost you will need to pay for any appointment, service, test, treatment, or care. Your insurance company should be able to tell you how much they will pay, how much of the cost goes to your deductible, and what your total obligation would be.

Step 8: Speak with the Providers’s Financial Manager

Tell the Financial Manager that you are trying to manage your health care costs, and that you would like to discuss opportunities to reduce the costs of the services you’ve been told you’re likely to need.

Step 9

Go over the estimated costs you received from the provider. Once the amount owed is agreed upon, mention to the billing manager that the amount is much higher than you expected or can afford, and ask if they can offer any discounts.

Quick Tip:

26. Do Not Accept an Initial Offer

As mentioned earlier, it is very common for providers to offer a 10% to 20% discount in exchange for payment in full within a few weeks. If you are offered a small discount, respond by thanking them for their consideration, remind them of your financial challenges, and ask them if they can offer you a bigger discount if you were able to pay them in cash or with a guaranteed check within 10 days.

Step 10

No matter what their response do the following:

Thank them for their help.
Ask them if they can send you an email confirming their discount offer.
Ask them if it would be OK if you talked again tomorrow or the next day after you see if you can raise the amount due in cash.

Step 11

Compare their discount offer with the fair prices you found during your research.

Step 12

Call back within a few days.

Explain that you have some more information that you would like to discuss, and ask to schedule time to meet in person. If they will not meet in person ask if they have time to talk now, or if they prefer to schedule time to talk within the next few days.

Step 13

Whether you meet in person, or speak via phone be prepared to show them the fair price that you found through research and getting price quotes from local competitors, and ask them if they would accept that amount as payment in full, or the Medicare Reimbursement rate.

Quick Tips

27. Don’t hesitate to ask to speak with a higher-level manager or the person’s supervisor if you can’t get the bill reduced to something you are satisfied with. As noted earlier, get the agreed upon fee and terms in writing.

28. If you don’t get a satisfactory result with the provider’s billing department, take the issue up by writing a letter to the executives; either the CEO or the CFO.

29. Get any agreement in writing.

Shopping for Prescription Drugs

Drug prices vary a lot between pharmacies. If you compare prices and use coupons and discounts, you can save up to 80%. Several websites and apps that help you find prescription drug assistance programs are;

The Partnership for Patient Assistance (PPA). This organization will help you determine if you qualify for help through any of the current programs being offered. PPA offers a single point of access to more than 475 public and private programs, including nearly 200 offered by pharmaceutical companies. Many people get their medications through PPA connections free or nearly free. There are no fees to get help from a PPA representative. You can also call them using their toll-free phone number; 888-477-2669

RxHope. This is a free program helps people to get medications that they otherwise could not afford. They offer to advocate for people by supplying information and help.

RxAssist. Another free program that is sponsored by pharmaceutical company AstraZeneca. The program offers a comprehensive database of pharmaceutical company patient assistance programs, as well as practical tools, news, and articles so that health care professionals and patients can find the information they need.

NeedyMeds. This group is a non-profit organization with the mission of helping people who can’t afford to pay for their medications.

GoodRx.com. Their website and companion mobile apps let you collect and compare prices at more than 70,000 U.S. pharmacies, find free coupons, and find the lowest price at local pharmacies without having to sign up or use your credit card.

Asking for a No Interest Payment Plan

Another option is to offer to make monthly payments. Most providers will want to be paid in full as soon as possible. However, it is possible to spread payments out over five years or more with no interest. If you are making reasonable payments you may not even be charged interest. This can save you money and keep you from putting yourselves in an uncomfortable position financially if you can’t afford to pay all of your charges.

Step 1

Contact the service provider’s finance department.

Step 2

Ask to speak to a manger who can discuss and authorize a payment plan to help you pay your bill. Be prepared to provide your account and/or bill numbers, as well as personal information that will help the provider validate who you are.

Step 3

Inform the finance manager that you…

Are paying for the services yourself.
Have limited income and financial resources; (be prepared to specify and prove your income).
Want to pay your bill.

Step 4

Ask them if they can work out a payment plan with no interest.

Finding Free and Low Cost Health Care

Free and discounted health care is available from free clinics, Medicaid, insurance companies, pharmaceutical companies, health organizations, local charities, and even hospitals and health systems. If you have a low income and are requesting 100% charitable care make sure to inform the provider of your situation, and ask for an application for charitable care. You will be asked to prove your income.

Quick Tip

30. The Patient Advocate Foundation (PAF) provides free case managers to help consumers. Get help by calling 800-532-5247, or using their website at http://www.patientadvocate.org. They help thousands of patients & families every year.

Government Assistance Programs

To find government assistance programs go to the website www.GovBenefits.gov. The online screening tool is free, easy-to-use, and confidential. You do not have to give them any personal information like your name, phone number, or social security number. You will be prompted to input your location and some information about your circumstances.

After you answer a series of questions about yourself you get a list of government benefits programs that you may be eligible for and information about how to apply.

Free Clinics

There are many free clinics throughout the U.S. that will provide services for people who do not have insurance or the income to get care from private practices. You can find a free clinic by searching on the National Association of Free Clinics website.

Rural Health Clinics

There are more than 3,500 Rural Health Clinics (RHC) located in rural areas throughout the U.S. The purpose of a RHC is to provide primary care services in under-served rural areas. Each clinic typically provides physician services and onsite laboratory testing. However, services vary from clinic to clinic. Most RHCs have arrangements with hospitals to provide services not available at their location. Patients who visit an RHC may see a physician, nurse practitioner, or physician assistant. RHCs are also offering more tele-health and in-home visits by registered professionals.

Quick Tip

31. You need to check into the services of the clinic you are going to attend.

Community Health Centers

The U.S. Department of Health and Human Services provides assistance through federally funded community, migrant, and other health centers. You pay what you can afford based on your income level. Health centers are in most cities and in many rural areas. You can find the ones closest to you on their website by typing your address into the search box on the home page, and clicking “Find Health Centers.”

The services typically include:

Checkups when you’re sick.
Treatment when you’re sick.
Complete care when you’re pregnant.
Immunizations and checkups for your children.
Dental care and prescription drugs for your family.
Mental health and substance abuse care if you need it.

Health Fairs and Preventive Screenings

The evidence is overwhelming that finding health problems early is good for your overall health and finances. Recently, insurers, hospitals, employers, and many community organizations have begun offering free health screenings to help find health problems early. The following tests are often available for free at local health fairs:

Cholesterol – this test can cost $100 to $300 if you need to pay for it from your doctor.
Skin exam – having your skin examined by a dermatologist costs $50 to $150 on average depending on your insurance.
Blood pressure – Making sure that your blood pressure is check helps lower your risk of many serious illnesses. This test can cost $70 to $200 during a typical visit to your doctors’ office.
Eye exam – After age 40, our vision begins to deteriorate. You’re also at increased risk of glaucoma and other illnesses. Full exams can cost from $50 to $150 with an optometrist, and $75 to $200 with an ophthalmologist.
A1C blood test – this is a major screening test for diabetes, and it measures blood glucose. This test costs $40 to $260, and if you have high blood pressure the test is often covered in full through your health insurance.
Colonoscopy – this tests identifies colon cancer risk factors, and allows physicians to remove potentially precancerous polyps. The cost of this test ranges from $1,100 to $2,800.

Common Screenings for Women

Pap smear – cells from your cervix are collected to screen for precancerous changes. The cost ranges from $75 to $350 if the test is done in your gynecologist’s office.
Mammogram – an x-ray of your breasts is used to screen for cancer. There is some controversy about when these tests should begin (age 40), and how often they should be conducted. The cost range for this test when done in your doctor’s office is $150 to $350. You can use the following toll free numbers from the U.S. Department of Health and Human Services to find local, accredited facilities that offer free and reduced fee mammograms;
- National Cancer Institute: (1-800-4-CANCER)
- The American Cancer Society: (1-800-ACS2345)
- National Alliance of Breast Cancer Organizations: (1-800-719-9154)
- The Susan B. Komen Breast Cancer Foundation: (1-800-IM AWARE)
- ME National Breast Cancer Organization (1-800-221-2141). Y-ME Spanish Language Hotline (1-800-986-9505)
DEXA Scan – this is an x-ray test to measure bone density. It is recommended for women older than 65. The cost ranges $60 to $385.
HPV (Human papilloma virus) – This is often done at the same time as Pap test. It checks for strains of HPV that are most likely to cause cancer. The cost ranges from $30 to $125.

Local Hospitals

Do not overlook your local hospital as a source of low cost and discounted health care. Some excellent hospitals are required to provide free care and services to their community. If you owe bills or need care that you can not pay for contact the department of social or patient services at the hospital where you were treated or intend to be treated. Explain your situation, and ask what help they can provide.

One of the best-kept secrets is that most large hospitals have clinic systems that provide some sort of discounted care to people without insurance, or free care for Medicaid patients. Many large hospital clinics must accept Medicaid outpatients, and in fact get paid quite well for treating them. These centers are staffed by medical residents in training who are smart, and they may even be better trained than other doctors in the community. In addition, all the resident doctors must have an attending physician in the clinic in case they need to consult with someone. Some hospitals even supply discounted medications to clinic patients.

The downside to using a large hospital clinic system is that your clinic doctor is not likely to be taking care of you when you are admitted to the hospital. Instead, you will be admitted as a service case, and other residents in training will care for you. But again, if you chose a top-notch hospital you could end up with better care than if you paid thousands of dollars out of pocket for care in a mediocre community hospital.

Clinics may be crowded, and it may be more difficult to get special tests or consultations, but again, the care could end up being quite good. Also, since residencies only last a few years you won’t have the same doctor for more than three years.

Federal Programs

In 2020, Hill-Burton free and reduced cost care was available at about 130 hospitals, nursing homes, and health care facilities throughout the country. These facilities are obligated to provide a reasonable amount of reduced fee and free care to people residing in the facility’s area who are unable to pay.

Facilities are required to provide this care because at one time they received grants and loans from the Federal government. Eligibility for care under Hill-Burton is based on the size of your family and your income. You apply for care at the facility where you were or will be treated.

To apply for Hill-Burton free or reduced cost care, follow the steps below:

Find the Hill-Burton obligated facility nearest you.
Go to the hospital or facility admissions or business office and ask for a copy of their Hill-Burton Individual Notice. The Individual Notice will tell you what income level makes you eligible for free or reduced-cost care, what services might be covered, and exactly where in the facility to apply.
Go to the office listed in the Individual Notice and say you want to apply for Hill-Burton free or reduced-cost care. You may need to fill out a form.
Gather any other required documents (such as a pay stub to prove income eligibility) and take or send them to the obligated facility.
If you are asked to apply for Medicaid, Medicare, or some other financial assistance program, you must do so.
When you return the completed application, ask for a Determination of Eligibility. Check the hospital or health system’s Individual Notice to see how much time the facility has before it must tell you whether you will receive free or reduced-cost.

You are eligible to apply for Hill-Burton free care if your income is at or below the current Health and Human Services “Poverty Guidelines.” You may be eligible for Hill-Burton reduced-cost care if your income is as much as two times (triple for nursing home care) the Health and Human Services Poverty Guidelines.

Care at a Hill-Burton obligated facility is not automatically free or reduced-cost. You must apply at the admissions or business office at the obligated facility and be found eligible to receive free or reduced-cost care.

Quick Tip

32. You may apply before or after you receive care — you may even apply after a bill has been sent to a collection agency.

Some Hill-Burton facilities may use different eligibility standards and procedures. Hill-Burton facilities must post a sign in their admissions office, business office, and emergency room that says: NOTICE – Medical Care for Those Who Cannot Afford to Pay, and they must provide you with a written Individual Notice that lists the types of services eligible for Hill-Burton free or reduced-cost care, what income level qualifies for free or reduced-cost care and how long the facility may take in determining an applicant’s eligibility.

Only facility costs are covered, not your private doctors’ bills. Facilities may require you to provide documentation that verifies your eligibility, such as proof of income. Although, Hill-Burton facilities must provide a specific amount of free or reduced cost care each year, they can stop once they have provided the amount specified.

Obligated facilities publish an Allocation Plan in the local newspaper each year. The Allocation Plan includes the income criteria and the types of services it intends to provide at no cost or below cost. It also specifies the amount of free or reduced cost services it will provide for the year. When you apply for Hill-Burton care, the obligated facility must provide you with a written statement that tells you what free or reduced-cost care services you will get or why you have been denied.

A facility may deny your request if:

Your income is more than the income specified in the Allocation Plan.
The facility has given out its required amount of free care as specified in its Allocation Plan.
The services you requested or received are not covered in the facility’s Allocation Plan.
The services you requested or received are to be paid by a governmental program such as Medicare, Medicaid, or insurance.
The facility asked you to apply for Medicare, Medicaid, or other government program, and you did not.
You did not give the facility proof of your income, such as a pay stub.

You may file a complaint with the U.S. Department of Health and Human Services if you believe you have been unfairly denied Hill-Burton free or reduced-cost care. Your complaint must be in writing and can be a letter that simply states the facts and dates concerning the complaint. You may call your local legal aid services for help in filing a complaint. Send complaints to:

Director, Division of Facilities Compliance and Recovery
5600 Fishers Lane, Room 10-105
Rockville, MD 20857

Free and Low Cost Care for Children

Shriners Hospitals for Children is an international health care system of 22 hospitals dedicated to improving the lives of children by providing specialty pediatric care, innovative research and outstanding teaching programs. Children up to age 18 with orthopedic conditions, burns, spinal cord injuries, and cleft lip and palate are eligible for care at Shriners Hospitals for Children. If approved the services are provided with no financial obligation to families. You can call the toll-free patient referral line at 1-800-237-5055 to see if your child or a child you know qualifies.

Medicaid

If you can’t afford to pay for medical care, Medicaid can make it possible for you to get the care that you need. Medicaid is a state administered program, and each state sets its own guidelines regarding eligibility and services. Medicaid is available only to certain low-income individuals and to families who fit into an eligibility group that is recognized by Federal and State law.

Medicaid does not provide medical assistance for all poor people. Income, assets and resources are all tested against established levels. Medically needy people who would be eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses.

The qualifications for Medicaid are different within each State, and within different groups. Even within the groups certain requirements must be met. Requirements may include…

Your age.
Whether you are pregnant.
If you are disabled.
Blind.
Aged.
Income
Resources; (like bank accounts, real property, or other items that can be sold for cash)
U.S. citizenship or lawfully admitted immigrant.

There are special rules for those who live in nursing homes and for disabled children living at home.

Quick Tip

33. You apply for Medicaid through your State.

If you or someone in your family needs health care, you should apply for Medicaid even if you aren’t sure if you qualify, and let a qualified caseworker in your state help evaluate your situation.

Medicaid does not pay money to you. It sends payments directly to your health care providers. Depending on your State rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services. Medicaid coverage is also available in every state for children living below the federal poverty level. That level may be slightly different in your state.

Healthcare.gov – 2020 Federal Poverty Level thresholds.

2020 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA
PERSONS IN FAMILY/HOUSEHOLD	POVERTY GUIDELINE
For families/households with more than 8 persons, add $4,480 for each additional person.
1	$12,760
2	$17,240
3	$21,720
4	$26,200
5	$30,680
6	$35,160
7	$39,640
8	$44,120

Children up to age 21 are eligible. In addition, states must provide Medicaid coverage for children up to age 6 with incomes below 133% of the Federal Poverty Level. This was $26,813 for a family of three in 2016. The Medicaid program served more than 30 million children in 2015.

Medicaid pays for a full set of services for children, including preventive care, screening and treatment of health conditions, physician and hospital visits, and vision and dental care. In most cases, these services are provided at little to no cost to the family.

Children’s Health Insurance

The Federal government and the states offer health insurance coverage for children through Medicaid and the Children’s Health Insurance Program, also referred to as the CHIP program. Programs typically cover tele-health, doctor visits, dental care, prescription medicines and immunizations, as well as services like hospitalizations and care for children with special health care needs. The programs serve families who are not able to afford health insurance coverage in the private market, or do not have coverage available to them. There can be premiums or other cost sharing associated with this coverage, but the programs are designed to be affordable.

Every state’s program is unique and has individual income eligibility rules and benefits covered, but in general, children in families with incomes around $44,500 per year (for a family of four) are likely to be eligible for coverage. You can find applications for every State at InsureKidsNow.gov. Just click on the State where you live and follow the instructions to apply.

Medicare

Medicare is health insurance offered by the Federal government to people who are 65 or older and meet specific eligibility requirements. Medicare eligibility requirements are detailed along with the entire program in their publication; Medicare & You.

The original Medicare Plan is a fee-for-services plan. Although, Medicare has been moving to a value-based payment system for several years. Medicare cvers many health care services and certain drugs. You can go to any doctor or hospital that accepts Medicare. When you get your health care, you use your red, white, and blue Medicare card. The Plan pays for many health care services and supplies, but it doesn’t pay all health care costs. There are costs that you must pay, like coinsurance, co-payments, and deductibles.

Medicare has four parts:

Medicare Part A helps pay for hospital bills.
Medicare Part B is a supplemental insurance option that pays for physician services and supplies outside of the hospital.
Medicare Part C includes private health plans that are Medicare approved.
Medicare Part D is prescription drug coverage. You must be enrolled in Medicare before you can apply for Part D coverage.

Medigap policies are intended to cover gaps in Medicare coverage, and sold by private health insurers. You can also add prescription drug coverage to your Medicare coverage by joining a Medicare Prescription Drug Plan. Medicare Advantage policies are also available for a monthly fee, and they can replace your Original Medicare Plan, and many include prescription drug coverage.

Raising Money for Medical Expenses

The Internet has enabled hundreds of millions of dollars medical fundraising. Online fundraising websites allow people to build custom pages, share them with friends and family, and receive donations from people who want to help. Many fundraising sites will have the user set a fundraising goal and a deadline. Some sites only award the funds if the total goal is reached by the deadline. Many fundraising websites charge a fee; often 5% to 10%. Make sure that you understand the financial arrangements, terms, and conditions before you start a fundraising campaign

Quick Tips

34. Successful fundraising can take time and effort. Try to build a small team of people to help. This will also increase the size of your network.

35. Try to make the first donation yourself. Many donors base their donation on the average size of pearlier donations. Donate as much as you can.

36. Make sure to ask for a specific donation amount for a specific reason by a specific date.

Here are several of the leading fundraising websites: GoFundMe, GiveForward, Induegogo

You can find more by searching on your favorite search engine.

It doesn’t hurt to ask a few friends to make some initial donations to get your campaign started. In fact, creating a team to help send “Thank You” emails and post updates to your fundraising page and Facebook will help you reach many more potential donors than trying to do everything yourself.

Sharing photos, information, and updates about the recipient on social media. Helps donors stay engaged. Consider using personal email to reach out to people you know, and always include a link to your fundraising page. Finally make sure to thank everyone in as personal a manner as you can.

Another creative way to use Facebook is to ask your friends to use their Facebook ”status” message for one day to: Help YOUR FRIENDS NAME”: (then include the URL of your campaign page). The thought is that many people might see it, and be interested in donating.

OTHER COST SAVING METHODS

Only Use the Emergency Room for Emergencies

Emergency room care is one of the most expensive options for medical care. Of course, don’t hesitate to go if you have symptoms such as significant severe shortness of breath or chest pain, uncontrolled bleeding or sudden weakness anywhere in your body, or any life-threatening condition.

Don’t Skimp on Prevention

Some of the most common reasons adults end up in the emergency room include falls, car accidents, fever, and chest and abdominal pain. Taking steps to reduce the risk of falls around the house, driving sensibly, getting your annual flu shot, paying immediate attention to pain, and properly cooking and storing food are just a few of many ways that you can avoid getting hurt or ill.

Obviously, getting on the healthy-living bandwagon: eating healthier foods, getting exercise, and stopping smoking will help. Regular exercise and a high-fiber diet that includes fruits, legumes, nuts, whole grains and vegetables can reduce your risk of heart disease and other chronic conditions. And stopping smoking not only cuts your risk of illness, but also saves you money. For example, a pack-a-day smoker could save $5 a day, or almost $2,000 a year.

Ask Your Doctor to Change Your Brand Name Prescription

Instead of throwing away your prescriptions, take another look at how much you’re paying. Generic drugs are equivalent in safety and effectiveness to their brand-name counterparts, but cost 30% to 80% less. Talk with your doctor about whether you can switch to a generic. If a generic isn’t available, ask your doctor about less expensive medication options.

Pay Attention to Where You Buy Your Medication

You may also be able to save money just by switching where you buy your medications. Many prescription plans offer a big discount if you use their mail-order pharmacy. And some retail chains offer popular generics for under $5 for a 30-day supply. If prescriptions are still too expensive for you a patient assistance program might be able to help. These programs, sponsored by drug companies, give free or low-cost medicines to people in need. Some also offer discount cards you can use at pharmacies. To find out if you’re eligible for an assistance program, ask your doctor or check online.

Never Pay a Medical Bill Before You Check It

Review your medical bills carefully and question anything that doesn’t look right. Read your policy, explanation of benefits statements (also called an EOB) and any paperwork you receive from your insurance company. Make sure you actually received the treatments for which you’re being charged, and check that you aren’t being charged twice for the same thing.

Stay In-Network

Confirm that your health insurance is accepted by your doctors and providers. Before you go to a doctor, get treatment, get tests, or get therapy, contact your insurance provider and make sure that each service provider’s charges will be covered by your insurance provider. If you do not have insurance contact the service provider let them know about your circumstances and ask how they can help you pay the charges

Avoiding Overcharges

To ensure you can review your medical bills you need to request an itemized bill from your doctor, hospital, and service provider when you arrive for service. By doing this you immediately put your service provider on notice that you are paying attention and that you are going to check the charges. The last thing most hospitals want is a patient going over their bills with a fine tooth comb. They would much prefer that you just receive their summary bill and pay them.

Quick Tip

37. Request an itemized bill when you schedule the service, or when you check in with your doctor, or at the hospital.

Don’t be intimidated by the hospital if they argue with your request for an itemized bill. It’s your money they are after. Any overcharges and things not covered by insurance are coming straight out of your pocket. If you simply accept the bill be prepared for the hospital to aggressively pursue payment. If you are told you will need to stay overnight find out from the hospital or facility’s billing department what you are being charged for your room by the day and exactly what those room charges cover. If small things that you need like tissues are not included, ask a family member or friend to bring them to you.

In the Hospital

Under no circumstances should you pay your bill before leaving the hospital. If anyone tells you need to pay your bill before you leave their facility, tell them you will review the itemized bill as soon as it is sent to you and make the payment due.

Avoid weekends. Unless you have a medical emergency, schedule routine procedures and hospital-check-ins during the week. Many hospital departments are closed during the weekend and have reduced staffs. This can quickly elevate the cost of your short hospital stay. If it can wait, check in on Monday. Additional Patient Guidelines for getting the highest quality care in a hospital will be available soon.

Keep Records

If you are feeling up to it, try to keep a record of your tests, medications, and treatments. One good way to do this is to use a micro-cassette recorder so you don’t have to write anything down. If you are not mentally able to keep a record of everything that goes on in the hospital, try to get a friend or family member to help you.

Before you leave the hospital see if there’s a financial counselor at the hospital. You might be able to call this person later to get their help negotiating the charges after you’ve reviewed an itemized statement.

Hospitals and providers will often lower prices in exchange for prompt payment; usually within a few weeks. Many physicians will negotiate charges too. Talk to your doctor and see if s/he will accept a lower payment. If you tell your doctor you are paying yourself, many doctors will accept the “usual and customary” payment that they would have received from an insurance company.

Wellness Programs

While the net effect of wellness programs is still under much debate, we know that employees who work at companies that offer these programs and participate in them can lower their health insurance premiums, and in some cases, earn rewards, merchandise and bonuses.

Choosing a Health Insurance Policy

It’s important to purchase a plan that includes your doctors and medications, and provides care for chronic conditions and free preventive screenings. Consider that as you get older, you’re likely to be using your health insurance more. Don’t forget your prescription drugs, dental care, appointments with specialists, tests that you feel that you’re likely to need, etc. Then, evaluate if it’s worthwhile to switch to a plan that covers more of these expenses, even if the monthly premium is higher than what you’re currently paying.

Quick Tip

38. Information online and on health insurance portals can be outdated. Once you have found plans with the benefits that you want, call your doctor’s office and double-check that they are participating in the plans that you are considering.

Choosing an Employer Sponsored Plan

If you feel that your monthly payments or premiums are a concern you can usually lower them by choosing a plan with a smaller provider network and referrals required for many services, This is called a HMO. Another option is to choose a higher deductible plan, or a plan with higher co=pays. The trade-off is that you’ll have lower monthly payments but you’ll cover more of your initial costs up front until you meet your deductible.

If you don’t want a high deductible and don’t mind higher monthly payments consider choosing a Preferred provider Organization (PPO) plan. With a PPO you’ll have more flexibility to choose doctors without higher out-of-pocket costs.

If you know that you’ll have some medical expenses you can may be able to take advantage of a health spending account. This allows you to set aside pretax dollars for your out-of-pocket medical expenses. There are two types of health spending accounts. A health savings account (HSA) and flexible spending accounts (FSA). HSAs are only available to people with high deductible plans. They have a benefit of allowing you to carry over your unused balance from year to year. With FSAs, you may lose any amounts that you don’t use at the end of the tax year.

If You Are Part of a Federal or State Marketplace

Increases in premiums and co-insurance are not limited to private health insurance. People who have purchased health insurance from a federal or state exchange can expect increases in premiums and co-insurance, too.

Solutions to manage these cost increases include:

Reapplying for the premium tax credit or health care subsidies offered by updating your income information.
If you can find a lower cost plan on the exchange, consider changing plans.
Consider applying for the Children’s Health Insurance Program (CHIP). In some states, a family of four might qualify for this assistance even if the household’s adjusted gross monthly income is over $7,000.
Use your insurance company’s nurse or professional hot lines to understand your conditions and treatments. This can help you eliminate unnecessary costs.

Your Insurance Company’s Payments to Providers

After any charges, your insurance provider will send you an explanation of benefits (EOB). It will say, “This is not a bill.” The EOB will tell you how much the hospital is charging, what your insurance will pay, and what you will have to pay. Review the EOB, and file it until all of the charges for all of the services are paid.

Financing Health Care

Health Savings Accounts (HSAs)

Health savings accounts are like personal savings accounts. However, the money in them can only be used for health care expenses. You, not your employer or insurance company, own and control the money in your health savings account. The money you deposit is not taxed, and you can invest it in stocks, bonds and mutual funds. To be eligible to open a health savings account, you must have a special type of health insurance called a high-deductible plan. Sometimes referred to as “catastrophic coverage,” high-deductible plans act like a safety net if you need extensive medical care.

Is a HSA right for you?

Like any health care option, health savings accounts have advantages and disadvantages. When considering a health savings account (HSA), think about your anticipated health care expenses, your financial situation and how much control you want over your health care spending. If you’re generally healthy and want to save for future health care expenses, an HSA may be an attractive choice. On the other hand if you anticipate needing expensive medical care in the next year and would find it hard to meet a high deductible an HSA might not be your best option.

The potential benefits of a HSA include:

You control how your HSA money is spent. Any unused funds stay in your account and can be used for future medical expenses.
You decide how much money to set aside for health care costs.
You can shop around for care based on quality and cost.
Your employer may contribute toward your HSA.
Money can be placed in your HSA on a pretax basis or may be deducted from your taxable income.

The potential risks of an HSA include:

People who are older and sicker may not be able to save as much as younger, healthier people who need less medical care.
Illness can be unpredictable, making it hard to accurately budget for health care expenses.
Some information, including cost and quality, can be difficult to find.
Pressure to save the money in your HSA might lead you to forgo care.
If you withdraw money from your HSA for non-medical expenses, you’ll have to pay taxes on it. If you’re younger than age 65, you’ll have to pay a 10 percent penalty, too.

Sources: American Medical Association, 2010; Kaiser Family Foundation, 2010; New England Journal of Medicine, 2006; U.S. Department of the Treasury, 2010.

Who can set up a HSA?

You can start an HSA on your own through a bank or other financial institution, or your employer may offer an HSA option. To qualify for an HSA you must be under age 65 and carry a high-deductible health insurance plan. If you have a spouse who uses your insurance as secondary coverage, he or she also must be enrolled in a high-deductible plan. This high-deductible health insurance plan must be your only health insurance coverage. You can’t be covered by other health insurance. However, having dental, vision, disability and long term care insurance doesn’t disqualify you from having an HSA.

How does a high-deductible insurance plan work?

As its name implies it’s a health insurance plan that has a high deductible; (the amount of medical expenses you must pay annually before coverage kicks in). The premiums – the regular monthly fee you pay to obtain coverage- for a high-deductible insurance plan are typically lower than premiums for traditional insurance plans.

However, a high-deductible plan doesn’t start paying until after you’ve spent a thousand dollars or more of your own money on health care expenses. (This unpaid portion of expenses is known as a deductible.) You can use your HSA to pay deductible expenses, co-pays, coinsurance payments and other non-covered health care expenses.

Not all high-deductible insurance plans work the same. For instance, some cover preventive services, such as mammograms, before the deductible is met. Review the plan’s coverage details carefully, including the out-of-pocket maximum, which is the limit on how much you would have to pay out of pocket for medical expenses in a year.

Spouses and Dependents

Even with company sponsored insurance it is becoming more important to check how much it will cost to include your spouse and dependents on your policy. Some companies are now asking their workers to pay 100 percent for spouses and kids.

Short Term Disability Insurance

If you have short-term disability insurance find out exactly what your benefits are by talking to your company’s human resources representative so you know exactly what you will receive, when you’ll receive it, and for how long. Employers are not required to offer long-term disability insurance.

A typical long-term disability policy pays about 60% of your salary and starts when short-term benefits have been used up. The length of time you receive long-term benefits can range from 5 years to life. Long-term disability policies vary widely. Talk to your human resources representative at work and find out if you’re covered, what is covered, and how long you can receive payments. It’s also important to know if your employer’s plan considers other benefits you may be receiving (Social Security disability benefits, for example) when figuring out how much long-term disability pay you’ll receive.

Health Insurance

Personal health insurance is the first place you should look for financial help as a hospital patient. Review the details your health insurance policy if you have one. There should be clear terms and conditions regarding what about your hospital visit or stay will be covered. Clarify any confusing points with a representative from your health insurance provider prior to your hospital visit if possible.

Case Management and Financial Assistance Planning

Case management departments specialize in helping hospital patients determine the best financial assistance options for their care. Consult a case manager or financial assistance planner from your health insurance provider or the hospital you stay in. They can help you come up with a plan to pay your hospital bills, or find a hospital or facility that you can afford.

Public and Non-Profit Health-care Facilities

Visit a public or government-run hospital if you are worried about being able to afford necessary services. These facilities provide care for people who cannot afford to pay upfront. Depending on your income, there may not even be any charges at all. Some non-profit health-care facilities provide similar free and low-cost services. Discuss these cost-efficient hospital alternatives with a social worker or case manager. Either health-care professional will be able to help you find such an institution that is convenient for you.

Medical Tourism

Medical tourism is helping patients find quality care at prices significantly lower than in the United States. Patients can have elective or necessary surgeries at a fraction of the cost, often less than 50% of the cost in the U.S.

For example, in vitro fertilization is a high cost procedure that is typically not covered by health insurance. In the U.S., the cost of an IVF cycle costs around $12,000, before medications which cost an additional $3,000 to $5,000. In places like Brazil, Spain, Russia, South Africa, and Israel the cost range from $2,500 to $6,000, and the success rates at many facilities are equal to and even greater than those in the United States.

Almost 1 million U.S. citizens sought healthcare services outside of the U.S. in 2014. With Mexico, Thailand, Costa Rica, India, and Singapore as the countries with the most medical tourism. Patients Beyond Borders, a resource for medical travelers, published their list of the top medical tourism countries, treatments, and the related savings as compared with the U.S. costs. They are:

Country	Treatment	Estimated Savings
Antigua (St. Johns)	Addiction & recovery	40%
Barbados (Bridgetown)	Fertility/IVF	40%-50%
Brazil (Sao Paulo, Rio)	Cosmetic surgery	20%-30%
Costa Rica (San Jose)	Dentistry	30%-70%
Hungary (Gyor, Budapest)	Dentistry	40%-75%
India (New Delhi, Mumbai, Bangalore)	Orthopedics & cardiology	50%-85%
Israel (Jerusalem, Tel Aviv)	Fertility/IVF	30%-50%
Malaysia (Kuala Lumpur, Penang)	Health screenings	70%
Mexico (Monterrey, Tijuana, Juarez)	Dentistry, bariatrics	30%-60%
Singapore	Cancer	30%-40%
South Africa (Cape Town, Johannesburg)	Cosmetic surgery	40%
Thailand (Bangkok, Phuket)	Various services	40%-75%
Turkey (Istanbul)	Vision (Lasik)	40%-50%

Common Procedures Done Oversees

Stem cell treatment and therapy is now being used to treat and prevent many diseases, although results are still somewhat unproven. The costs for this type of treatment can range from $15,000 to $20,000.

According to the Explore Stem Cells organization, South Korea has made huge advances in this area. Tummy tucks have become very popular in recent years. A tummy tuck in Mexico costs $4,500 compared to $8,000 in the U.S. Although, the standards of care in other countries may not be as high as in the U.S. So, check carefully into the success and complication rates of any provider you are considering.

Without insurance, the cost of dental implants averages $2,600 to $5,000 in the U.S., and that does not include the fess for the dentist, or any other medical professionals. The same procedure costs $477 in Hungary. Although, airfare to Hungary ranges from $600 to $3,000.

Quality hip replacements with top, English speaking doctors are available in Belgium at 50% to 70% discounted rates then in the $40,000 it would cost on average in the U.S.

Spinal fusion and cataract surgery are also procedures that people have been able to save money on, and still receive quality care when going abroad.

Procedures that may not be as safe or cost effective to have overseas include; any procedure that requires follow up or extensive rehabilitation, rhinoplasty, weight loss surgery, in vitro fertilization (IVF), liposuction, skin tucks, breast implants, leg lengthening, hysterectomy, and chest or abdominal surgery. Any cost savings from having these procedures done overseas is offset by the potential of lower medical standards, lengthy rehabilitation, the difficulty of fixing problems, travel costs, and increased safety risks.

What you need to know:

If you have insurance, call your insurance company to find out if they will cover the procedure if it’s done in a foreign country. Choose a hospital accredited by the Joint Commission International. This means that the hospital has a high standard of care.
Don’t forget to add the costs of airfare, and any costs associated with recovery time.
Standards are not always the same in foreign countries. Be very careful to check the safety and success records of any facility and doctor that you choose. The Joint Commission International (JCI) is the leading accrediting organization for medical sites around the world.
Make a plan for communicating with friends and relatives back in the U.S. If you can avoid it, do not use your cellphone overseas or you may pay huge fees from your U.S. carrier. Instead, buy an unlocked world phone and a SIM card for your country of destination.
Consider that malpractice litigation, regulations, and follow-up care may be very different if you choose medical tourism.

Quick Tip

39. Have a plan prepared in case something goes wrong. Know what you will do before anything happens.

Being Your Healthiest Saves Money

People with chronic illnesses can benefit a great deal by working to be as healthy as possible. Two of the best ways to lower your medical bills are 1. To invest the effort it takes to be as healthy as possible, and 2. To find anything that seems wrong with your health as early as possible so it can be checked out.

Eventually, almost everyone will experience health problems. If you pay attention to symptoms, you can take care of any issues them before they become bigger, more expensive, more life-threatening problems. Even if you have no insurance at all you can still go to one of the many free health fairs and screenings to get basic preventive services. Not only will you spend less going to the doctor and on co-pays for prescriptions, you may qualify for some benefits from your employer, and you’ll avoid more invasive and expensive treatments.

Ignoring symptoms and warning signs increases your health risk and likely costs virtually 100% of the time. If self-treating anything for a short period doesn’t help you feel better, contact a medical professional. There are too many free resources available to let the cost of medical care stop you from contacting a doctor, or having needed treatment.

Patient Rights and Protections Under U.S. and State Laws

Last revised: 10/05/2023

Too many times, people give up the fight for their own health and well-being because it’s not always easy. This article helps to clarify the current rights that patients have been granted and are enforced through our federal and state laws.

The patient rights that we hear people refer to most often are the right to…

1. Receive clear and understandable explanations in order to choose a treatment or a course of action based on the available options and their benefits, the risks, the likely outcomes, and the alternatives. This is commonly called Informed Consent.
2. Refuse treatment.
3. Make decisions about end-of-life care.
4. Obtain your medical records, including doctor’s notes, medical test results, and other documentation related to their care.
5. Be treated with respect by providers, practitioners, and payers.
6. Privacy of your medical records; (see HIPAA, 1996).

Let’s start by looking at the key patient rights as guaranteed by Federal law.

Informed Consent

Informed Consent is intended to ensure that a patient can make a well-informed decision about their care. It is a process where a health care provider educates a patient about the benefits, risks, likely outcomes, and alternatives of a procedure, test, intervention, or course of action. At its core informed consent means that a patient must be provided with and understand the information needed to make decisions about their health care; including 1. Their diagnosis, and 2. The purpose, benefits, risks, likely outcomes, side effects, and alternatives of any proposed test, surgical procedure, medical procedure, treatment, or course of action.

Patients also have a responsibility to ask their physician and health care providers to explain what things mean. If a patient does not fully understand the benefits, risks, and likely outcomes of any course of action they need to keep asking for an explanation of what everything means until they do understand. In most cases patients are asked to provide their written consent for any course of action to proceed.

Certainly, there are situations such as emergencies or extremely fragile patients when it may not be possible to get informed consent. In most cases parents can give informed consent for their minor children. Although state laws very and some states do make exceptions for minors to provide informed consent.

Patients must be competent to give voluntary and informed consent. This means having the ability to make an informed decision. Doctors often refer to this ability as having decision-making capacity. To have decision-making capacity a patient must understand their options, the risks and consequences, and the costs and likely benefits of the consequences. Mental illness, mental retardation, alcohol and drug intoxication, altered mental status, brain injury, and age restrictions are all examples that may make a patient incapable to provide their consent.

Refusing Treatment

Patients have a right to refuse treatment in most cases. Exceptions are;
1. Emergencies when immediate treatment is needed for the patient’s safety or to save their life.
2. When patients have an altered mental status due to drugs, alcohol, brain injury, or illness.
3. Parents can’t refuse life-saving treatment for a minor.
4. When refusal of treatment poses a threat to the community.

End-of-Life Care

Patients have the right to refuse life extending treatment at the end of their life. This right was guaranteed to Americans through the Patient Self-Determination Act of 1991. It requires nursing homes, home health agencies, and others to provide patients with information on advance directives. Advance directives are designed to give instructions on the medical interventions a person wants once they have had emergency treatment. It is usually directed towards the staff at a hospital, nursing home, or home care agency.

A relatively new document called a Physician’s Orders for Life-Sustaining Treatment (POLST) is available to patients with chronic or life-threatening illnesses in some states. A POLST is designed to instruct emergency personnel on what actions to take while you’re still at home.

Your Medical Records

The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), provides individuals with a legal, enforceable right to see and receive copies upon request of their medical and other health records maintained by their health providers and health plans, and to direct the covered entity to transmit a copy to a designated person or entity of the individual’s choice. This includes medical records; billing and payment records; insurance information; clinical laboratory test results; medical images; wellness and disease management program files; and clinical case notes; and other information used to make decisions about individuals. Psychotherapy notes maintained separate from the rest of the patient’s medical record, and information compiled in anticipation or use in a civil, criminal, or administrative action are excluded from this right of access.

Privacy

HIPAA laws do not keep all others, other than the person, their doctors, and their caregivers, from accessing an individual’s medical records. Individually identifiable records, which contain personal attributes, and aggregated medical records, in which individuals can’t be identified, are both shared and purchased. Under HIPAA laws covered entities have a right to access your medical records if they follow strict rules. Covered entities include doctors, allied medical professionals, facilities, technology providers, payers, and the government.

The general guidelines under HIPAA are;

1. You have a legal right to copies of your medical records.
2. You can designate someone else to get copies of your medical records.
3. Your health care providers have a right to see and share your medical records with others who you given permission.
4. Any payer that pays for a portion of your health care may get a copy and review your medical records.
5. Federal and state government may have a right to your medical records.
6. Companies that keep prescription databases may have information on your prescription drug purchases that they sell to life and disability insurance companies.

Rights in Emergency Departments

Under the Emergency Medical Treatment and Active Labor Act of 1996 (EMTALA), you have a right to emergency care if you are in any incident that is life-threatening or sever, or where bodily functions or organs are seriously impaired, or any incident where delivery is imminent in a pregnant woman. Under EMTALA emergency departments (ED) must:

1. Provide a screening examination.
2. Stabilize anyone with an emergency medical condition.
3. Arrange for transfer to another facility if the ED can’t stabilize you.

You cannot be turned away because you can’t pay. Although, you are responsible for the full bill, even if you don’t have health insurance. There are many ways to work out payment arrangements, including charitable care. If you go to an emergency room for a non-life-threatening prenatal care, wellness checks, health screenings, follow up, doctor visits, or non-life-threatening conditions such as flu, fever, colds, rashes, sore throats, etc., you do not have a right to care.

Other Federal Laws

The Patient Protection and Affordable Care Act (ACA) of 2019

The Affordable Care Act includes a Patient Bill of Rights (PBR) that gives Americans the following protections:

a. Section 1557 prohibits discrimination in the basis of race, color, national origin, sex, age, or disability in certain programs and activities. Section 1557 also extends protections granted under Federal civil rights laws, including, (Title VI of the Civil Rights Acts of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975) to individuals participating in 1. Any U.S. Department of Health and Human Services (HHS) funded or administered program or activity, and 2. Health Insurance Marketplaces and all plans offered by issuers participating in those Marketplaces.
b. Requires insurance plans to cover people with pre-existing conditions, including pregnancy, without charging more.
c. Free preventive care.
d. Ends lifetime and yearly dollar limits on the coverage of essential health benefits.

The Stark Law

The purpose of this law was to curb physician self-referral, or referring patients to hospitals, labs, home health services, medical equipment and devices, therapy. Lab, and other entities or services
from which they or a family member, benefit financially.

The Anti-Kickback Statute

This statute prohibits transactions intended to induce or reward referrals for items or services reimbursed by the federal health care programs. The statute is designed to protect federal program health beneficiaries from the influence of money on referral decisions.

The Health Information Technology for Economic and Clinical Health Act (HITECH)

The HITECH Act was enacted as part of the American Recovery and reinvestment Act (2009) to promote the meaningful use of health information technology by incenting health care providers to adopt electronic health records and adopt privacy and security protections.

The Genetic Information Nondiscrimination Act (GINA) of 2008

GINA protects Americans from being discriminated against based on their genetic information in health insurance and employment.

State Laws

Many states have enacted laws on the use, collection and disclosure of health information. Some states even detail what each person’s medical record must include. States have also set standards for privacy and confidentiality that often exceed federal laws. Others have set standards for how private health insurers conduct business within their state. For example, because Medicaid is a partnership between the federal government and the states, many states have passed their own regulations on participating providers.

Surprise Medical Bills

Surprise medical bills often occur when someone is treated in an in-network hospital emergency department or facility by out-of-network physicians or other health professionals. As of mid-2019 twenty-eight of the states had enacted consumer protections. As of mid-2019 only thirteen states had protections that limited the consumer’s financial exposure, extended protection to both hospital emergency departments and in-network hospital settings, applied to both HMO and PPO members, prohibited balance billing, and adopted a payment standard or process to resolve payment disputes between providers and payers. The Commonwealth fund as provided an interactive map that reviews the Balance-Billing protections for each state.

Conclusion

Many patient rights are rooted in the American Medical Association (AMA) Code of Medical Ethics. The AMA Code of Medical Ethics guides physicians in their patient and physician interactions, treatments & use of technology, and in their professional relationships and self-regulation. The Patient Bill of Rights (PBR) details each patient’s rights and responsibilities to help improve the quality of your care.

National and state health care laws are changing. It’s important to research the latest laws when you have an issue with your payers, providers, or doctors. We will attempt to update this article as new information becomes publicly available. However, when you have an issue a healthcare attorney in your state should be consulted to ensure that you know the latest federal and state laws.

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Last Revision: 03/26/2021

Start Lowering Costs by…

Finding Help

Your Doctor(s)

Your Health Insurance

Fighting Coverage Denials

Managing Surprise and High Cost Medical Bills

Start by Getting an Itemized Bill

Using a Professional Medical Billing Advocate

Check Your Medical Bill Yourself

Unexpected Bills from Balance Billing

Up-coding

Unbundling

Negotiating Costs

After You’ve Received a Bill

Negotiating Before Receiving Services

Here’s how to price shop:

Shopping for Prescription Drugs

Asking for a No Interest Payment Plan

Finding Free and Low Cost Health Care

Government Assistance Programs

Free Clinics

Rural Health Clinics

Community Health Centers

Health Fairs and Preventive Screenings

Common Screenings for Women

Local Hospitals

Federal Programs

Free and Low Cost Care for Children

Medicaid

Children’s Health Insurance

Medicare

Raising Money for Medical Expenses

OTHER COST SAVING METHODS

Only Use the Emergency Room for Emergencies

Don’t Skimp on Prevention

Ask Your Doctor to Change Your Brand Name Prescription

Pay Attention to Where You Buy Your Medication

Never Pay a Medical Bill Before You Check It

Stay In-Network

Avoiding Overcharges

In the Hospital

Keep Records

Wellness Programs

Choosing a Health Insurance Policy

Choosing an Employer Sponsored Plan

If You Are Part of a Federal or State Marketplace

Your Insurance Company’s Payments to Providers

Financing Health Care

Sources: American Medical Association, 2010; Kaiser Family Foundation, 2010; New England Journal of Medicine, 2006; U.S. Department of the Treasury, 2010.

Spouses and Dependents

Short Term Disability Insurance

Health Insurance

Case Management and Financial Assistance Planning

Public and Non-Profit Health-care Facilities

Medical Tourism

Common Procedures Done Oversees

What you need to know:

Being Your Healthiest Saves Money

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Last revised: 10/05/2023

Informed Consent

Refusing Treatment

End-of-Life Care

Your Medical Records

Privacy

Rights in Emergency Departments

Other Federal Laws

State Laws

Conclusion

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