During her first pregnancy in 2020, Newton’s Julia Remington* thought she was doing everything right to avoid surprise medical costs. But after what she understood was a routine, doctor-prescribed ultrasound, she received an unexpected bill for hundreds of dollars. When she called her health care insurer to inquire, she was told the procedure wasn’t covered because a doctor was not present. This nuance, she says, which had not been articulated to her and she didn’t know to ask about, was a crushing realization.

“I had done my research beforehand, calling my insurance company before we began trying to conceive to review what was and wasn’t covered, and in my understanding, ultrasounds were covered with pregnancy,” she says. “My health care provider didn’t have an ultrasound machine in their office, so I had to go where they send people for ultrasounds. I live in a major city [that’s] a health care capital. How is this right? What happens if you live in a health care desert? That can’t be the policy. And they’re like, ‘Well, it is.’ I was floored.”

This experience left her more wary and more prepared to handle insurance for her second pregnancy, for which she switched to Blue Cross Blue Shield Massachusetts (BCBSMA). The prior unexpected bill, which she had to pay, prompted her to ask more questions in advance of each procedure about precisely what the insurer did and did not cover. She also looked into her new plan with BCBSMA to understand her coverage, from ultrasounds and breast pumps to pelvic floor therapy and acupuncture. After bringing home baby number two, she was relieved to find no unexpected bill waiting. This time, her research throughout the pregnancy and more comprehensive coverage through BCBSMA meant the entire hospital stay was covered.

What is an unexpected bill?

Remington is not alone. As health care costs continue to rise and coverage remains a top source of confusion, more patients are speaking out about “surprise” charges.

Unexpected medical bills, or a charge for a medical appointment, procedure, or emergency-room visit that a patient did not anticipate, affected nearly half of insured, working-age adults in a Commonwealth Fund study. Unexpected bills can amount to as much as $2,600 per episode with patients who have private health insurance, according to the National Institutes of Health.

In 2022, the Federal No Surprises Act disallowed any out-of-network medical bill for patients receiving care without prior notification from the provider. But patients can still be confused about coverage and their financial responsibility, especially considering the myriad circumstances surrounding one office visit and each patient’s unique insurance plan and health needs. 

Common scenarios behind surprise bills

Surprise bills most often arise from specialty services like anesthesiology, radiology, and lab testing. These providers frequently operate on different networks and billing structures, which means a patient can receive out-of-network charges even at an in-network facility. Ambulance transport and emergency room visits can carry similar risks. Even a routine checkup can lead to extra charges. If your primary care provider recommends a specialty test, like lab work or imaging, that service may have its own copayment or be billed separately toward your deductible.

In-network: Clinicians who have a contract with the health insurer for a patient’s specific coverage to provide services at a set price.

Out-of-network: Clinicians who are not contracted with the health insurer for a patient’s care.

Copayment: A fixed amount a patient pays for a covered medical service at the time of the visit, with the remaining cost covered by their insurance.

Deductible: The amount of money a patient must pay for medical services before health insurance chips in.

“This can happen a lot if you don’t know [the details of your plan],” says Dr. Karl Laskowski, vice president of clinical programs and strategy at BCBSMA and a primary care general internist. “It could be a misunderstanding of what your coverage is.”

How to lower your risk

To prevent unexpected medical bills, “you should ask your provider questions. They should be able to give you an estimate of the costs and fees they’re going to charge up front,” Laskowski says. “You should also reach out to your health insurer. At BCBSMA, we have a plethora of resources, like a member portal, Find a Doctor that helps members find in-network providers, our app MyBlue, and a member service team who can help. This way you can have a better understanding, know what to expect and any potential barriers, and help prevent this kind of thing from happening.” 

Patients should be their own advocates, Laskowski emphasizes. It helps to understand your individual or family health insurance plan, and what it does or does not cover for any planned medical service or procedure. Know your deductible, or the amount you must pay for medical services before health insurance contributes. 

For unplanned emergencies, no one expects patients to have every detail memorized, but knowing how to use available resources, like insurance apps, member support, and asking the right questions afterward, can help avoid surprise costs later. It’s also important to understand general financial responsibilities, such as what your insurer typically pays for emergency room visits and related testing.

Through the MyBlue member portal and Find a Doctor & Estimate Costs tools, BCBSMA members can check network status and estimate out-of-pocket costs before an appointment. 

The following are questions you can ask your doctor and administrative staff ahead of a medical procedure:

• What exact service are you providing? 
• How much will it cost?
• What additional lab tests, specialist referrals, or appointments are needed and how will that be covered under my health insurance plan?
• What tests are you ordering?

The following are questions you can ask your insurer in advance of a medical procedure:

• Does my provider accept this plan?
• How will the procedure and additional testing or specialists be covered under my plan? 
• Will the services need any type of prior authorization to ensure coverage?

Even with careful preparation, mistakes and misunderstandings can happen. If you receive a bill that doesn’t seem correct, start by reviewing the itemized charges to make sure the services and dates match your records. Next, call your insurer to confirm whether the charges should have been covered, and reach out to your provider’s billing office. You can also ask about appeal or payment options. BCBSMA representatives are available to guide you through next steps and connect you with resources to help manage the costs.

When it comes time to pay

Once armed with this knowledge, patients will still be charged for a medical service in some capacity.

Depending on a member’s plan, it may be wise to establish a Health Savings Account (HSA) or Flexible Spending Account (FSA) to help offset out-of-pocket charges when they arise. Meanwhile, BCBSMA member services can answer questions and help individuals navigate their plan, Laskowski advises.

Health Savings Account (HSA): A private account patients establish for pre-tax savings, tax-free growth through investment, and tax-free withdrawals for eligible medical costs.

Flexible Spending Account (FSA): An employer-sponsored account that lets you set aside pre-tax dollars for eligible medical expenses within a calendar year.

“So what do I do differently?” Remington asks. “I am sure to call insurance beforehand and ask what’s covered, but then ask, even though something is covered, [I ask] are there scenarios in which I might get a surprise bill anyway? I think I have more self-advocacy in terms of what I might ask of a doctor’s office.”

*Name has been changed to protect privacy