Prepare before care · Lesson 5 of 16
What should I check before an appointment or procedure?
The short answer
Before planned care, check three things: that the provider and facility are in your network, whether you need a referral or prior authorization, and what it may cost. Ask your plan and the provider. Write down who you spoke with and when.
Key takeaways
- The doctor and the hospital or surgery center can have different network status.
- One procedure can create several bills, such as for the facility, surgeon, anesthesia, and lab.
- Federal rules protect you from many surprise out-of-network bills, but not every situation.
A few questions before planned care can prevent costly surprises.
Network
In-network providers have agreed prices with your plan. Out-of-network care usually costs more, or may not be covered. Check both the clinician and the place of care, using your plan's directory and by calling the plan.
Referrals and approvals
Some plans require a Referral from your primary care doctor before you see a specialist. Some services need prior authorization, which is plan approval in advance. The provider's office often requests it, but you can ask whether it was approved.
Cost estimates
Ask your plan for an estimate of your share. Ask the provider for the billing codes and the expected price. If you are uninsured or paying without insurance, you can ask for a good faith estimate in advance.[1]
If you pay without insurance
Usually, the provider must give you a good faith estimate when you schedule care at least 3 business days ahead, or when you ask. This applies if you have no insurance or choose not to use it. You do not need to use the words "good faith." Ask for it in writing and keep a copy.[2]
Each estimate covers only one provider or facility. For surgery, ask the surgeon and the hospital for separate estimates. You will not get an estimate during emergency care.[2]
Separate charges
A hospital or clinic may add a facility fee. Other clinicians, such as anesthesia or radiology, may bill separately. Ask who else may be involved and whether they are in your network.
Surprise bills
Federal law protects most people from surprise bills for most emergency care and for some out-of-network care at in-network hospitals and surgery centers.[1] These protections have limits. If you get an unexpected bill, check whether they apply.
What can be different for you
Network rules differ by plan type. HMOs often require referrals and cover little out-of-network care. PPOs usually cover some out-of-network care at a higher cost. Medicare, Medicaid, and some states have their own billing protections. Your plan documents and state insurance department can tell you more.
More detail (optional)
If the bill is $400 or more above the estimate
You may be able to dispute the bill with the federal patient-provider dispute process:[3]
- You did not use insurance, and you told the provider before your care.
- One provider or facility billed at least $400 more than its own estimate.
- You start within 120 days of the first bill. You need the estimate, the bill and a $25 fee.
An independent reviewer decides what you owe. Disputing cannot raise your bill. While the dispute is open, the provider cannot send the bill to collections or charge late fees.[3] If you used insurance, this process does not apply. Our complaint guide shows where to go instead.
Writing it down
Note the date, the name of the person you spoke with, and any reference number. If something goes wrong later, these notes help in a dispute or appeal.
Emergencies
In an emergency, get care first. Billing questions can wait. Federal protections limit many surprise bills for emergency care.[1]
Words in this lesson
- In-network
- Providers and facilities that have a contract with your plan for agreed prices. Usually costs you less.
- Out-of-network
- Providers and facilities without a contract with your plan. Care often costs more or may not be covered.
- Referral
- A written order from your primary care doctor to see a specialist. Some plans require it.
- Good faith estimate
- A written estimate of expected charges that you can ask for if you are uninsured or not using insurance.
- Surprise billing
- An unexpected bill from an out-of-network provider you did not choose. Federal law protects against many of these.
- Facility fee
- A charge from a hospital or clinic for the use of its space, staff, and equipment, separate from the clinician's fee.
- Prior authorization
- Your plan's approval before certain care. Approval is not a guarantee of payment.
Related
Where can I go for help?
Free help is often close by: the member services number on your insurance card, the billing office for your provider, your state insurance department, and nonprofit patient advocates.
This is general education. For decisions about your own plan, taxes, or legal rights, check your plan documents or a qualified professional.