Tips for Avoiding Surprise Medical Bills

Medical debt has a substantial impact on Americans’ personal finances. About 36% of U.S. households have medical debt, with a total of more than $220 billion owed. A big part of the problem is “surprise” medical bills that can catch people off-guard. Half of adults say they couldn’t cover an unexpected $500 medical bill without going into debt—with 19% saying they wouldn’t be able to pay it at all.

Surprise medical bills often occur when someone receives care from a provider or facility that is not in our network. A patient may be billed for the difference between the Blue Cross Blue Shield allowed amount and what the out-of-network facility or provider originally charged. This is called “balance billing,” and with today’s high health care prices the effects of this can be devastating.

You can avoid surprise medical bills by asking questions in advance and shopping around for care. This can help reduce financial burden and prevent the stress of unexpected bills. We’ll give you some tips and action steps you can take to prevent surprise bills from landing in your mailbox.

What You Can Do

• Use in-network providers. Providers and facilities that are part of our network have agreed to accept the Blue Cross Blue Shield allowed amount as payment in full and cannot balance bill our members. You won’t get a surprise balance bill if you choose providers and facilities that are in our network. To find in-network care, use our Find-a-Doctor tool or call our customer service team at (800) 247-2583 (TTY: 711).
• Ask if any out-of-network providers will be used. Sometimes out-of-network providers can be used without a patient’s knowledge. For example, samples are sent to an out-of-network lab for testing, or a surgery includes an out-of-network anesthesiologist. This can result in unexpected bills. Always ask if there will be any out-of-network providers or facilities involved in your care. If so, ask that in-network resources be used instead.
• Get a cost estimate. People are often shocked by how expensive health care is. You should know what your care will cost up front, how much your health plan will pay, and what your out-of-pocket cost will be. Use our online cost estimate tool, available in the Member Resource Center (MRC), to get an estimate of the total cost and what portion you’ll pay. Our customer service team can also assist you with obtaining a cost estimate. Many facilities have cost estimate tools on their websites as well.
• Shop around for care. Prices for health care vary greatly between different providers or facilities. Choosing a lower-cost option can potentially cut your out-of-pocket costs by thousands of dollars. To learn more about lower-cost options and how to shop for health care, visit vtaffordablecare.com
• Verify prior approvals have been received. For some services, we require advanced review of proposed treatments. This process is called prior approval or prior authorization. Vermont providers in our network are required to submit prior approval requests on behalf of our members. Network providers who are out of state typically obtain prior approval, but are not required to do so. For out-of-network services, members may need to be involved in getting prior approval. To guard against surprises, you should check with your provider to verify that prior approval has been received for services that require it. The Outline of Coverage and Certificate of Coverage documents available in the MRC will have more information on when prior approval is needed. 
• Know your deductible. A deductible is the amount you’ll have to pay each year before your health plan begins paying its share. To prevent surprises, you should know what your health plan’s deductible amount is. You can find that out by logging in to the MRC. If you have one of our high deductible health plans, you can use a health savings account (HSA) to save money tax-free to pay for care. Learn more in our blog article on everything to know about HSAs.
• Check your copays or coinsurance. After the annual deductible has been paid, most of our plans require you to pay a portion of the Blue Cross Blue Shield allowed amount through copays or coinsurance until the out-of-pocket limit has been reached. Become familiar with your plan’s copay and coinsurance requirements so you won’t be surprised by out-of-pocket costs. You can learn more by viewing your Outline of Coverage and Certificate of Coverage documents in the MRC.
• Understand what’s covered or excluded. It’s helpful to know what items your health plan covers and what services are excluded—the services you would be responsible for paying in full. Check your plan’s Outline of Coverage and Certificate of Coverage documents in the MRC. Be sure to read the section on excluded services. Our customer service team will be glad to answer any questions you have.
• Learn your protections under the law. The federal No Surprises Act went into effect Jan. 1, 2022, providing protections for consumers against surprise medical bills in some situations. Read more in our blog article on protection against surprise medical bills.

Know Before You Go

Knowledge is power when it comes to protecting yourself from surprise medical bills. If you verify in advance that providers and facilities giving you care are in our network, shop around for lower-cost options, and get an up-front cost estimate, you can greatly reduce the chance of an unexpected medical bill. Our best advice is: know before you go. It can save you from having a financial headache later.