I just heard a frightening story that could happen to ANY of us. I’m compelled to share when I hear something scary, gross or bizarre – I think it helps to get it out of my mind when I pass it off to someone else. Because of this odd phenomenon, I’m writing about it. You’re welcome. 

Here’s the story…

One day in November of 2014, a man (we’ll call him John) took his child to a local ER/Urgent Care. His bill ended up being the following under his insurance plan…

Total Original Price = $1,600

Insurance Paid = $1,100

His Total Out-of-Pocket Cost = $500

Then, in January of 2015, John had a simple medical issue that caused something more concerning. So, back to the ER/Urgent Care center he went. This time, his bill looked like this…

Total Original Price = $6,800

Insurance Paid = $3,400

His Total Out-of-Pocket Cost = $3,400

WHAT? The man and his child received similar care at the same facility in the same location. On visit #2, why did he have to pay almost 7 times more out-of-pocket?  Here are 4 reasons this can happen and some handy tips to help… 

1) Similar care isn’t necessarily similar!

While it might seem to a non-medical outsider (like you and me) that both John and his child had similar care, you really can’t compare prices from one visit to another. Unfortunately, while we can do that with most other products/services, it doesn’t work this way with health care. The visits outlined in my story were with two totally different people, who had two totally different ailments, requiring 2 totally different doctors and 2 totally different sets of testing and/or procedures and/or medical supplies. As a result, the price of each visit is going to be different. 

2) When insurance companies change, prices change!

In the story above, John changed insurance companies from November 2014 to January 2015. Insurance companies work with every local provider (docs, hospitals, imaging centers, urgent care centers, etc.) to negotiate what they will pay for thousands of procedures or services. In this case, John’s first insurance company had negotiated a different “deal” with this urgent care center than John’s current insurance company. How would he know? Unfortunately, he wouldn’t. One thing you CAN do is…

3) Know your network!

If your insurance company has negotiated a price with a provider, that provider is considered “in the network” for your insurance company. This is why you almost always get a better price when you go to a provider who is “in your network.”  If you go to a provider who is “out-of-network,” you’re probably going to pay much more – they can charge you any amount and bill you personally for what your insurance company doesn’t cover. It’s always good to know the ER and urgent care centers near your home that are in-network vs. out-of-network. In this case, the facility John visited was in-network for both insurance companies – but at very different prices. Regardless, it’s important to have a good idea of the providers that are in-network for your insurance plan BEFORE you need them. Speaking of needing care…

4) Be sure it’s an emergency!

Are you having heart attack symptoms OR do you just have symptoms of a sinus infection? Those are two totally different things – one qualifies as an “emergency” and the other doesn’t. If you’re going to an emergency room, it’s going to be expensive – it is, after all, the most technologically advanced room in your entire city! So be sure your illness is deserving of the attention and expense. It’s worth thousands of dollars to get it right.

Consider subscribing to a telehealth service. These services provide 24/7 access to general practitioners, pediatricians, internists, etc. via phone or video. In most cases, you can contact them quickly for advice on best next steps based on your symptoms. The cost of having this type of service for your family is nominal considering the $3,000 bill you could pay for a bottle of Pepto if those stomach pains turn out to be a simple case of food poisoning! 

Now let’s hear your story! Have you had a surprise medical bill? What did you do? Do you have questions? Feel free to post them in the comments below or email me at heidi@freshbenies.com.