You have a good chance to hold down your medical bills through preparation, research, negotiation, and keeping a good attitude. Let’s walk through some recommendations by category. As you go through this advice, remember that you need to help yourself first by taking care of yourself. As one Alaska physician observed, the most cost-effective way to interact with the health care system is not to need it.
Choosing Where You Get Your Medical Care
- Seek in-network providers: Before you choose your primary care provider (physician, nurse practitioner, or physician’s assistant), imaging facility, or specialists, you should make sure that you choose within your insurance-preferred provider network if possible. If you are being referred for testing or consultation, you can make sure that you ask your referring provider to choose among your in-network providers, one that the primary care provider thinks would provide high-quality care.
- Lab work: If you need blood work, your clinic can manage the most common blood tests. Specialty blood work can be done at local medical laboratory testing facilities. Shop around, as there are wide variations in price.
- Avoid the ER if you can: Get the “right level of care.” If you have a life-threatening emergency, you should go to the emergency room. If you do not, go to a walk-in clinic or urgent care facility if you can’t get to your regular primary care provider. Several groups of primary care providers in Anchorage have clinics operating after regular business hours, and many are in network with insurance providers. In most instances, the most expensive place that you can receive care is in the ER.
At the Clinic, Office of the Primary Care Provider, or the Emergency Room/Emergency Department
- Come prepared to describe your complaint in detail to the doctor, nurse, nurse practitioner, or physician’s assistant. If your problem has been evaluated before, know what tests have been done—and it is even better to keep records. This allows the provider to have the best information and avoids the problem of providers ordering up a bunch of tests to determine what you could have told them.
- Ask questions. Listen carefully to the answers. Take notes. (You could also audio record the discussion on a smartphone.) If you don’t know what is happening, you can’t make an informed decision.
- Bring a relative or friend: If you think that you need help, get a trusted, tough-minded relative or friend to assist you as your patient advocate. This person can be your second set of eyes and ears, although if you can you should be speaking more than the patient advocate. Unless there is a language barrier, health care providers prefer that you describe your symptom in your own words.
- Ask questions: Sample questions include: Why is this procedure being ordered? Why do you think I need this test that you recommend? What about this medication that you want to prescribe? What are the alternatives? Steel yourself with these truths: Medical providers expect questions, and you have the right to say “No.” And never assume that all the medical personnel have all the relevant information. If you have an insurer, get pre-approval from that insurer for procedures.
- It is OK to ask a provider “How will the results of this test change the way that my condition is managed?” Sometimes providers reflexively order tests. Making sure that tests are truly necessary based on evidence-based guidelines will reduce your overall costs. Make sure as well that the tests are performed at facilities that are in your network.
Medications
- Ask for generics: Make sure that you ask about “generics” and medications that are offered at relatively low prices on your insurance “formulary” (an official list giving details of medicines that may be prescribed). This information is readily available on many physicians’ electronic medical record systems. You can also check your insurer’s formulary to find what drugs in the same class are preferred. Check the $4.00 medication lists offered by most chain pharmacies and big box stores before filling prescriptions.
- There are two free applications ( https://www.blinkhealth.com/ and https://www.goodrx.com/) which can be downloaded for a comparison of medication charges at local pharmacies.
If You Get Admitted to the Hospital
- Pre-approve your admission: If you are going to be admitted to the hospital, get your health insurer to pre-approve that admission.
- Clarify your status: As Dr. Elisabeth Rosenthal notes in her book An American Sickness, you should be clear on the status of your stay. Ask whether you are on “observation status” or are instead being admitted into the hospital, because the answer might well have a big impact on your finances. Although they are still in hospital beds, patients on observation status will be considered outpatients and be on the hook for outpatient co-payments (the dollar amount associated with a type of care) and deductibles (the amount that you pay out of pocket before your insurance starts to pay), which are generally far higher than those for an inpatient stay. (And unless you get a terrific justification of why you need a private room, turn down that honor unless you want to risk a much higher bill.)
- Ask about the length of stay: Ask for an estimate of how many days you will spend in the hospital (but be prepared to get the answer “You will be in the hospital for only as long as it takes for me to discharge you safely”).
- Ask for a financial counselor: If you are worried about your ability to pay, ask to speak to one of the hospital’s financial counselors.
- Make sure your providers are in your network: At least one of the documents you will be asked to sign upon admission to the hospital will cover your willingness to accept financial responsibility for charges not covered by your insurer. Dr. Rosenthal recommends that before you sign such a document, you write in “as long as the providers are in my insurance network” (that is, under contact with your insurance provider). Dr. Rosenthal also passes on the advice that you insert on every chart you see the words “Consent is limited to in-network care only and excludes out-of-network care.” Dr. Rosenthal suggests that such an annotation will at the very least give you a basis for contesting charges later.
- Document your care: Identify and document every person who appears at your bedside, and identify and document every test, procedure, and medication you are given. (Make your requests for this information with a smile, as this will reduce the defensiveness that might otherwise arise.) Get a patient advocate to do this if you are unable. Try to take your own home medications at the hospital if you can. Refuse unnecessary equipment. Talk to the doctors, nurses, and aides who come into your room; key times include the morning (when doctors usually make their rounds) and during nursing shift changes.
After You Are Discharged from the Hospital
- Review the billing statements from all sources. Get itemized bills so that you check the costs of each medication, lab test, and procedure. Keep track of any claims and payouts by insurers. Be prepared to dispute charges, and do so on a timely basis. Keep careful notes documenting the date, time, person contacted, and content of communication. Work to decipher the codes on the bills. Don’t be afraid to call to figure out what a bill and a code mean. “It is your right as a patient and health consumer to know what you are paying for,” as health care specialist attorney David J. Holt told Mikey Box of time.com. Ask for discounts and write-offs, and you might find that an in-person visit to the office of the provider might yield the best results.
- Work hard to avoid taking out a loan to pay your medical bills, whether that loan comes from the financial institution or from your provider. If necessary, go higher up the chain of command for an answer or a justification of the charge. Finally, be prepared to complain to state or federal regulatory agencies if you can’t get relief otherwise.
If You Have Been Told that You Need a Big-Ticket Procedure
- Non-emergency surgeries performed in Alaska are both costly and some of the biggest reasons our state’s health care costs are higher than those of any other state. This is particularly true for procedures done by specialist practitioners such as orthopedic surgeons, cardiac surgeons, and neurosurgeons.
- Be skeptical if you are told that you need something new, fancy, and expensive. The most cutting-edge procedure or technology is not necessarily the best course for you, and a doctor’s high fees are no guarantee of quality. For example, if your knee or shoulder is hurting, that pain might go away if you started swimming and/or had some physical therapy, and you might not need that MRI test or surgery that a surgeon advised.
- Don’t pressure doctors to give you the most high-dollar or invasive treatment you have ever heard of, and don’t let them pressure you either. A second opinion is critical, particularly if the first specialist you see recommends an expensive procedure or treatment. As one hospital executive says, don’t be a victim.
- It is often helpful to ask your primary care provider “If your mom was going to have this surgery done, where would you send her?”
- If you do decide that you need big-ticket surgery, research your options. Websites such as www.fairhealthconsumer.org can give estimates of what various procedures should cost in locations around the country, and they can give you the CPT code as well for the procedure. In general, it is better to go on the Internet after you have a diagnosis as opposed to trying to diagnose your problem on the Internet yourself.
- The next step is to negotiate. Be assertive. Get price comparisons, either in the office or by telephoning. Announce that you are investigating several providers for options and that you seek the most favorable prices. More than one Alaska doctor has expressed amazement that patients appear afraid to question doctors about recommended work and request discounts the way that those patients would if the recommendations came from an automobile dealership or an auto body shop. As one Alaska doctor said, “Providers know that health care costs in this state are high and most/many are willing to help you determine the most cost-effective and safe options if you just ask.”
- A representative from Angie’s List told time.com that a prospective patient should get the quote in writing with a signature, name, and title along with the price quoted.
- Additionally, that observer—Cheryl Reed—recommended that “When getting prices, be sure you cover all fees associated with your procedure, rather than just the surgical costs—e.g. anesthesiologist, radiologist, laboratory costs, etc.”
- Another tip: Be wary of a surgeon whose office puts you on the surgical schedule as soon as you call the office for an appointment.
- If you decide that your best option is for a surgery outside of Alaska, be aware that you might have difficulty securing follow-up care from an Alaska surgeon upon your return to the state. One Alaska physician recommends that anyone considering going outside the state for surgery to remain at that location long enough to be reasonably certain that complications have not arisen.
Before You Need the Medical Care
- The easiest advice is both the most boring and the most important. A high percentage of your lifetime medical costs is likely to be determined by your nutrition and your lifestyle, so start by taking care of yourself before you are told to strip down and get in a gown.
- Eat healthy food, exercise regularly, quit smoking, limit your alcohol intake, and establish visits with a primary care provider.
- Know important facts like your blood pressure.
- Make a list of the medications you take and keep it in your wallet or purse or on your smartphone.
- Know who your primary care provider is and what specialists you see.
- And to help your family, you should go to the next level and prepare an advance health care directive/living will to lay down your wishes for your care when you can’t do the speaking yourself. Share that directive with your family and your medical care providers—and you could also suggest to relatives that they also prepare such a document for themselves.
Cliff Groh prepared this document following conversations with more than a dozen Alaska medical providers and others knowledgeable about the provision of health care in Alaska. Particular thanks go to Theresa Philbrick, RN; the book An American Sickness: How Healthcare Became Big Business and How You Can Take it Back by Elisabeth Rosenthal, and the article by Mikey Box entitled “7 Smart Ways to Negotiate Your Medical Bills.” The above is not intended as legal advice, even though Groh is a lawyer as well as a writer and the Chair of Alaska Common Ground. Alaska Common Ground is holding a series of events on Alaska’s high health care costs that runs from November of 2017 through January of 2018, and details can be found at www.akcommonground.org or on Facebook.
