Healthcare expenses are the biggest potential threat to your finances because, unlike other things we purchase, we frequently don’t know the full price upfront. Even having good insurance won’t guarantee that your out-of-pocket expenses won’t break the bank if you become seriously sick or injured. However, you can shop ahead for most non-emergency services and items before receiving care and estimate your out-of-pocket healthcare costs – with or without insurance.

In our blog article, How Price Transparency Helps Reduce Out-of-Pocket Costs, you learned how the Transparency in Coverage Rule, Hospital Price Transparency Rule, and the No Surprises Act each feature ways to access pricing information before receiving healthcare services. We’ll now learn to estimate medical expenses for planned non-emergency healthcare services and items.

Estimating Healthcare Costs When Using Insurance

To estimate out-of-pocket healthcare costs when using insurance, start by understanding your insurance policy’s coverage details. Refer to your Explanation of Coverage (EOC) and be prepared for any expected costs. 

Request an Advanced Explanation of Benefits (AEOB) from your insurance company when scheduling or at least 3 business days before the procedure. 

The AEOB must include the following information: 

• Network status of the provider or facility
• Contracted rate for the item or service
• Good faith estimate from the provider or facility
• Good faith estimate of the amount covered and any cost-sharing you’ll owe
• Good faith estimate of the amount you have incurred towards meeting deductibles and out-of-pocket maximums as of the date of the AEOB
• Disclaimers indicating whether coverage is subject to any concurrent review, prior authorization, and step-therapy or fail-first protocols
• Disclaimers indicating the information provided is only an estimate based on the items and services reasonably expected to be furnished, at the time of scheduling (or requesting), and is subject to change
• Other information or disclaimers from your insurance plan

Estimating Healthcare Costs Without Insurance

You can also estimate healthcare costs when uninsured (self-pay) or not using insurance. Request good faith estimates from all healthcare providers and facilities involved in your scheduled service or procedure.  Make this request at least 3 business days in advance and include:

• Expected charges for furnishing the service or item
• Any ancillary items or services reasonably expected to be provided in conjunction with those items or services, including those by another provider or facility
• Expected CPT billing and diagnostic codes for these items or services 

If it’s at least $400 more than the estimate, you may be able to dispute your bill.

Try Negotiating

When researching pricing, you may discover the provider you prefer charges more than others in the same area. You can try using this information to negotiate with your chosen provider. The provider will know you’ve researched fair pricing, won’t have the hassle or expense of dealing with insurance middlemen, and may prefer to keep your business.  

Strategies for negotiating planned, non-emergency healthcare services and procedures:

• Start negotiating at the Medicare rate. It’s the lowest rate paid for medical services in the U.S. Try explaining to the provider that this is what you can afford.

If the provider won’t accept the Medicare rate, you can try:

• asking the provider to match the price of another provider 
• paying the cash price
• offering a lump-sump down payment in exchange for a sizeable discount

Medical Tourism, But Not What You Think

When you hear the term “medical tourism”, many people think of the horror stories in the media of major surgeries gone wrong in foreign countries.  Or perhaps, you think of people hopping Mexican and Canadian borders for dental work or prescription drugs.  However, it can also refer to getting care much closer to home.  

One savvy shopper traveled 90 miles, from Austin to San Antonio, Texas with a friend to save $1800 on LASIK surgery. That $1800 more than paid for the trip for two, gas, dinner, and a nice hotel on the Riverwalk – with money left over! 

By researching pricing for a needed thyroid ultrasound, the same patient found imaging services across the board were much cheaper – sometimes half price – outside of the large metropolitan areas.  Additionally, she found imaging services from ambulatory surgical centers to be about a third of the cost of the same imaging test at a hospital outpatient facility.

Depending on your situation, it may make sense to check prices at facilities in areas further from home. 

Price Transparency Tools for Medical Services and Drugs

Medical facilities have been slow to comply with new requirements to post their prices online. You may need to make a few phone calls to get estimates when the providers’ websites aren’t helpful. 

However, as more hospitals and healthcare centers post their prices, technology is racing ahead to help us make sense of all the data. Tools and apps are being developed to help us shop around and compare pricing. 

Some sources can get pricing information:

• Search using AI chatbot (such as Chat GPT)
• https://www.medicare.gov/procedure-price-lookup/cost/
• https://www.fairhealthconsumer.org/
• https://www.mdsave.com/
• https://clearhealthcosts.com/clearhealthcosts-price-check/

Another way to save money is with prescription drug savings cards. SingleCare is a free online tool that allows users to shop around for the lowest prescription drug prices, similar to GoodRx. Crush Medical Debt recommends SingleCare, which usually provides better prices than other RX discount cards. Additionally, SingleCare works for your entire family and can often beat the price of an insurance copay. Download your free SingleCare card here.

Takeaways

• You can shop ahead and get estimates for many non-emergency healthcare services and items.
• If insured, request an AEOB from your insurance company at least 3 business days before your scheduled procedure.
• If uninsured or not using insurance, request a good faith estimate at least 3 business days before your scheduled procedure.
• Armed with price research, try negotiating with your provider, starting at the Medicare rate.
• Depending on where you live, you may save money by traveling a little further from home for healthcare services.
• Download your free SingleCare card to shop for the lowest prescription drug prices.