After a recent trip to the doctor, I saw firsthand how much of an opaque maze it is trying to figure out the price of a doctor visit. I also realized that I am one of the few people who, in some masochistic way, would actually enjoy navigating through doctors, front desk associates, and insurance support staff to find answers.
After hours of research, below is what I discovered about:
- Why healthcare pricing is so complicated
- 8 financial tips every time you visit the doctor
I hope my experience can help you. Let’s get to it.
Why is Healthcare Pricing So Complicated?
Doctor’s offices and hospitals are, at the end of the day, businesses. It is the doctor’s full-time job to offer you a service (medical care), and get paid for that service. And as such, each doctor has the ability to set his/her own prices for the services they provide. That’s why visiting Dr. Sally may cost $500, but Dr. Emma may charge $800 for the same treatment. There is nothing weird or evil about this. It is capitalism at work.
Here’s where it gets tricky though. Almost nobody pays, or even sees, the full “sticker price” that doctors charge. That’s because there is a middleman in this story; your health insurance provider. I happen to be insured through Cigna.
Your health insurance company negotiates special pricing discounts with certain doctors. These doctors are then considered “in-network.” Your insurance company negotiates with each doctor on an individual basis, so you could be charged differently depending on which doctor you see, even if both those doctors work in the same office!
Finally, add in the fact that your insurance company offers many different plans for you to choose from. Each of these plans vary in their premiums, copays, deductibles, co-insurance amounts, out-of-pocket maximums, and more. I personally have a high-deductible healthcare plan.
So you have lots of overall reasons why the price you pay can vary:
- Multiple doctors, each charging different amounts
- Multiple insurance companies, each negotiating those amounts
- Multiple insurance plans, each with different pricing structures
Each of those steps ultimately has an effect on how much you get billed for a particular service, and is why this process gets very messy, very fast.
8 financial tips every time you visit the doctor
Just because healthcare pricing is complicated, doesn’t mean you should give up. And it doesn’t mean there aren’t things you can do to still beat the game. Below are 8 ways you can save money and stress when visiting the doctor.
1. Stay In-Network
This has a couple key benefits. First, you will likely get a lower rate. Second, your payments will count towards your deductible.
My insurance provider, Cigna, makes it incredibly easy to verify a doctor is in-network. I can call their support line to ask, or I can go online and see for myself.
Here’s where it gets tricky though. If your primary care physician (PCP) recommends you see a another doctor (a specialist), you have to make sure that other doctor is also in-network. AND, if that other doctor needs to send something, for example bloodwork, to a lab, you have to also make sure that lab is in-network.
You must make sure that every hospital, doctor, lab, etc. that will be providing you services is in-network. This means asking your doctor which lab they will be sending your samples to, before they send it.
My PCP is on top of things and reminded me to confirm this before scheduling an appointment, but the responsibility is ultimately on you as the patient.
2. Ask for CPT Codes
Now that you’ve verified your doctor is in-network, it’s time to estimate the price of the service you will be receiving before you step foot in the doctor’s office. It’s not easy to do, but it is possible with a little secret called a Current Procedural Terminology (CPT®) Code.
A CPT® Code is a numerical code governed by the American Medical Association (AMA). Almost every medical procedure has a unique code that doctors use to bill patients for procedures. Just like each house has its own address to identify it, each procedure has its own CPT® code.
These codes allow patients like myself to estimate the price of a doctor visit ahead of time.
While I was scheduling my appointment, I asked the front desk what CPT® code they would be using to bill me. The lady informed me it would be coded as 99202, which is for a new patient visit, and that the hospital’s cost of 99202 is $350.
Luckily, my doctor is in-network, so I wouldn’t have to pay that full $350 price. I quickly called up my insurance company, told them the name of the doctor and the CPT® code, and was told the estimated cost would only be $116. That is basically a ⅔ discount!
But even more important than the discount, I knew the price of my doctor visit before it happens, which gave me piece of mind and allowed me to budget for it. Without it, there’s almost no way to estimate the cost ahead of time.
3. Price Shop
Much like other products and services you might purchase, not every store charges the same price. That’s why it can be valuable to look at a few different stores before buying that expensive TV. Medical procedures work the same way.
Different doctors charge different prices for their services. And insurance companies negotiate with each doctors separately. This means that the price for a new patient visit (CPT® code 99202), will vary depending on which doctor I go to, and which insurance provider I have.
It can be smart to lookup a few different doctors in your area and ask your insurance provider what the price will be for each of them. Of course, price isn’t the only thing you should use to determine where you get your medical care. But it is an important factor.
4. Ask Before You Commit to Anything
Finally, you are in your doctor’s office and ready to receive whatever services you had scheduled. At the beginning of every appointment, before any services are provided, I recommend you request that your doctor inform you before offering any services outside the scope of the initial CPT® code.
For example, let’s say you have an exam because you aren’t feeling well. In that exam, your doctor says you may have the flu and would like to run a test to confirm. The initial exam is under one CPT® code, but that test may require an extra CPT® code, and thus an extra charge to you.
I don’t know anything about medicine, and I trust my doctor. So I likely will agree to whatever services they recommend. But I do want to be aware of what I am buying before I buy it, and that’s why I like my doctor inform me before performing any services. It only take a couple of minutes to speak with the front desk and my insurance company to confirm the price, and then the doctor can continue.
5. Read Your EOB
After you receive treatment from your doctor, he/she will send a bill to your insurance provider. This is why the front desk always asks for your insurance information beforehand. The bill will list what services were provided (remember those CPT® codes?), and how much was charged for each.
Then, your insurance company will review the bill and pay whatever portion they are responsible for, depending on your plan. Your insurance company will then send you an Explanation of Benefits (EOB), that breaks down any discounts they applied, what amount they paid, and what amount they believe you still owe. Below is what my EOB looked like.
Most people throw their EOBs away without reading them, but there is important information in there. Sometimes, mistakes are made, and you won’t know if you don’t read your EOB.
6. Read Your Bill
After the insurance company pays their portion, the doctor’s office will bill you for whatever is remaining. That’s when you will receive the final bill. Usually this takes weeks, because of all the communication that had to happen with the insurance company beforehand.
Again, you should read your bill, and verify that the information matches the CPT® codes and prices your were expecting, and the information in your EOB.
7. Keep Records
Much like your taxes, I recommend keeping records of your medical services and payments. Staying organized can help in many ways.
It can help you more accurately recall your medical history. You may also need proof of services and payments in order to ensure you are properly reimbursed or receive certain tax benefits.
Personally I use Google Drive to store all my medical records, which I find easier than storing physical paperwork. I keep my EOBs, my bills, and my proofs of payment. Every PDF is titled by date, so it is easy to sift through. I’m a little OCD with it, but that’s okay.
8. Reduce Taxes
Lastly, don’t forget to take advantage of the numerous tax benefits available for medical care. Each of these could be their own article, but take full advantage of any that apply to you. Things like a Flexible Spending Account (FSA), Health Savings Account (HSA), or Itemized Deductions for medical costs exceeding 10% of AGI. You can read about a lot of these in IRS Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans.
Personally, I max out my HSA, which saves me over $1,000 in taxes every year . And my wife has a Health Reimbursement Account (HRA) through her work. But learning what these are and how to use them takes a bit of research, so many people don’t use them, and thus leave money on the table.
Yes, healthcare is complicated. And yes, it’s expensive. But the healthcare game is not unbeatable. These 8 tips can help save you money and stress the next time you visit the doctor.
I run through these 8 tips every time I go to the doctor’s office, just to make sure I don’t forget one. I’ve also found that simply knowing how to “speak their language” with terms like CPT and EOB will let your doctor/insurance company know you are an educated consumer. That alone will help prevent you from getting taken advantage of.
Do you have any tips to add to this list? If so, comment below.