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The cost of medical care in the United States is notoriously steep. From prescription drugs to knee replacements, the US outspends all other wealthy countries for nearly every procedure or medical service. These exorbitant costs are shouldered by patients, with about half of American adults reporting difficulties affording health care costs, according to Kaiser Family Foundation polling. Among the 19 percent of American households that carried medical debt in 2017, the median amount owed was $2,000 per household, according to US Census Bureau data. KFF surveys also show that excessive medical prices disproportionately affect those who are uninsured, Black and Hispanic adults, and people with lower incomes.
The expense of medical care, paired with a lack of transparency around how much these services will cost and why, can add to the shock and terror that comes with a medical bill. However, patients have tools and negotiating power to reduce these costs both before services are rendered and after they receive a bill. While many patients may resign themselves to paying the bill, there are a bevy of other cost-cutting options to exhaust first. “You should never ever pay any medical bill right away,” says Caitlin Donovan, the senior director of the National Patient Advocate Foundation.
Unfortunately, the responsibility is solely on the patient or their guardian to advocate for themselves; hospitals and medical providers will often not readily offer cost-reducing alternatives. Knowing the right questions to ask can help patients reduce or even avoid huge medical bills.
What to ask while you’re still at the hospital, doctor’s office, or pharmacy
There are questions you can ask providers and pharmacists before you get a test, procedure, or prescription filled to ensure you’re not paying more than you need to. In emergency situations, some of these questions won’t apply since there may not be time to shop around when it comes to lifesaving care. In non-emergency circumstances, the first thing a patient can do to avoid a large bill for something as simple as an office visit is to visit providers that are in-network with your insurance if you have it. Your insurance carrier’s website or app will have a search tool for in-network providers. Also check the list of accepted insurances on the physician’s website. If you’re still unsure if a doctor is in-network, call your insurance carrier and speak with a representative. “A lot of the time when we see people with really big bills,” says Casey Schwarz, the senior counsel for education and federal policy at the Medicare Rights Center, “it’s because they’re trying to access something that’s either not covered or out of network.”
These bargaining tactics require a significant amount of time and energy, and are made considerably more difficult when you’re not feeling well or English isn’t your first language. Under the Affordable Care Act, patients who speak limited English are entitled to a free qualified interpreter and translated medical documents. Health care providers must inform patients that they offer interpreting services. When booking an appointment, tell the scheduler you will need an interpreter during your visit.
For non-emergency procedures and appointments at in-network physicians, here are some financial questions to ask before you leave the office.
How much will this cost?
Since 2021, federal law has required all hospitals to list pricing information online for services, such as blood work or X-rays, provided during inpatient admission and outpatient visits. These posted costs include the insurance prices and cash prices — that is, to pay without using insurance — which are often lower than insurance prices. However, studies found many hospitals did not list their prices, or if they did, the data was confusing and inconsistent. A review from the price transparency nonprofit PatientRightsAdvocate.org found that just a quarter of the country’s largest hospitals listed all of their prices for every single insurance carrier.
You should be able to access the price list on the hospital’s website (which can be a tricky process in itself; the New York Times has some tips on how to parse the data) but if you can’t, get in touch with the billing department to ask for the price. Make sure you’re looking at a spreadsheet of costs and not using the estimator tool, which Cynthia Fisher, the founder and chairman of PatientRightsAdvocate.org, says produces inaccurate estimates.
“Everybody should know what is that discounted cash price,” Fisher says. “What is my insured rate? How does my insured rate compare to other insurance rates? And guess what? You have the right to not accept that insurance rate if it’s egregiously higher.” In practice, this means informing the billing department that you do not want to use your insurance and will pay out of pocket.
Beyond the listed prices within hospital systems, if you are uninsured or will probably pay cash, health care providers must provide you with a “good faith estimate” in writing before you’re treated, says Dawn Greene, the operations manager at medical bill advocate service Resolve. These estimates include the cost of the procedure and any associated costs, like lab tests or anesthesia for a surgery. Should your final bill total $400 or more over the estimate, you can file a dispute with the provider. Those disputes should start with a call to the billing department.
For those with high-deductible insurance plans who are generally healthy and have historically never hit their deductible, it may be cheaper to pay cash, without using insurance, for a procedure or medication. “Let’s say that you have a serious medical issue, you’re going to be taking a lot of expensive medicines all the time, and you’re for sure going to hit your deductible. It’s better to go through your insurance so you can hit your deductible sooner and then you don’t have to pay for anything,” says Carolyn McClanahan, founder of financial planning firm Life Planning Partners. “But if you’re a normally healthy person, and you just come down with something short term, then if you have a high-deductible plan, it is probably better to pay cash.”
Check online databases like Healthcare Bluebook and Fair Health Consumer, which provide fair price estimates for many kinds of office visits and procedures based on your location, to make sure you’re being offered a fair price. The online tool Solv provides patients the costs for common procedures in their area if they’re not using insurance.
Should the listed cost for your insurance carrier or the cash price be beyond what you can spend, ask to see the financial assistance or charity care policy. “People don’t realize how many of them actually qualify for financial assistance from hospitals,” Donovan says. Each state or hospital will have their own eligibility requirements for financial assistance. In New Jersey and Massachusetts, for example, patients are eligible for free care if they have a family income of up to 200 percent of the federal poverty level. (The poverty guideline for a single person is $14,580 in 2023 and $30,000 for a family of four.) Even if you make more than that, you could still be eligible for a discounted rate.
If you’re still not comfortable with the price, you can research costs at other hospitals to find one that fits your budget. This can be time-consuming and frustrating, especially if you’re sick. While Donovan is not a proponent of shopping for care, she says patients can save money on imaging costs by opting for X-rays, ultrasounds, MRIs, and CT scans at freestanding clinics outside of hospital systems. So if it’s not urgent, it’s worth looking for the cheapest facility. You can call and ask for their rates over the phone, Donovan says.
How can I lower the cost of this medication?
Your doctor probably won’t know the exact cost of medication when they’re prescribing it — especially when it comes to what your insurance will or won’t cover — but they’ll know if there is a generic brand or even an over-the-counter medicine available that will undoubtedly be cheaper. You can even ask the pharmacist if there is a generic or OTC version of the drug they can give you instead. “Sometimes [doctors] prescribe pain medicine that’s actually equivalent to three Advil, 600 milligrams,” Fisher says. “Why pay for an expensive prescription when you probably have it at home in your medicine cabinet?”
Fisher recommends asking the pharmacist the price of the medication if you were to pay cash versus if it were to be covered through insurance. Often, the cash rate is much lower, she says. You can also ask the pharmacist if they have access to any discount cards or coupons from the drug manufacturer, Donovan says. Keep in mind that discount cards cannot be used with insurance.
Platforms like GoodRx offer price comparisons for medications at pharmacies near you and provide coupons for discounted medications. You won’t be able to use your insurance with GoodRx coupons. Mark Cuban’s platform Cost Plus Drugs lists discounted drug prices; your doctor will have to write the prescription to the company’s pharmacy partner, which will then mail you the medication. Cost Plus Drugs accepts Capital Blue Cross, Rightway, and other select insurances. Again, paying cash for these discounted options may be considerably cheaper than going through insurance.
Patients with Medicare are unable to use coupons from the manufacturer for drugs. However, many people are eligible for the Medicare Savings Program, which reduces drug costs down to a flat rate, says Schwarz, of the Medicare Rights Center. You can apply for the Medicare Savings Program through your state Medicare agency. There is an additional Extra Help program, which also reduces drug costs, that patients can enroll in through the Social Security Administration.
If you were prescribed medication for an ongoing or extended period of time, ask your doctor at your annual checkup if the medication is still necessary, McClanahan says. Eliminating or lowering the dosage of a drug will also lower your expenses. However, you should never defy your doctor’s instructions to take name-brand medication or scale back on dosage in order to save money.
Do I really need this test or procedure?
Sometimes doctors will order a litany of tests in order to diagnose a potential issue. The costs for even routine blood work can add up, depending on the labs ordered. Tell your physician you’re concerned about the cost of the tests, Donovan says, and ask something along the lines of, “I’m worried about finances. Are we getting a lot of value added for these tests?” For example, Donovan was told she would need monthly ultrasounds during one of her pregnancies — a considerable expense. “I was like, ‘That seems like low-value, high-cost care,’” she says. The physician quickly said the monthly ultrasounds weren’t necessary unless she experienced any complications.
“Here’s the thing about providers,” Donovan says, “as soon as you sound like you know what you’re talking about, all of a sudden they’re going to treat you like you know what you’re talking about.”
McClanahan suggests inquiring about what exactly the doctor is hoping to see in the test. “If they can’t answer that question, do you really need that test?” she says.
Can we keep the conversation limited to what the billing department would consider a preventative visit?
As a part of most health insurance plans, preventative services — like annual checkups, immunizations, and common screenings — are free. However, after reviewing a doctor’s notes from an appointment, some billing departments will categorize — or code — a free preventative visit as another type of appointment entirely, resulting in a bill. A doctor simply asking you how you feel emotionally can change the coding of a visit. “So many people come to us with that very same problem,” Fisher says.
Fisher says patients should feel empowered to tell their doctor, “This is my annual checkup. Let’s keep our conversation within the bounds of that type of visit,” while they’re in the exam room with their doctor.
If you’re being asked to pay while on the way out of the office, remind the person asking you for money that you were here for a preventative visit and to change the code on the visit. Should you receive a bill in the mail weeks later, call the doctor’s billing department and explain the situation: The appointment was coded incorrectly and you should not be charged. You may need to call your insurance company as well.
How to negotiate a medical bill
Opening a medical bill and seeing an astronomical number can come as a shock. After the procedure or appointment, patients must double-check the accuracy of billing departments and exhaust all other options to lower the bill before paying. Here’s where to start and what to ask for.
Can I see an itemized bill?
“It’s estimated that about 60 percent of medical bills that are issued have errors,” says Greene, of Resolve. Always ask to see an itemized bill to make sure you’re being charged correctly. Were you double charged for something? Charged for a service you did not receive? You can also compare the costs on your bill with the hospital’s posted prices to ensure you’re not being overcharged. “If they say a CT scan is $5,000 on their website and they’re charging you $6,000, then you know that there’s an issue with the billing and you bring that to the hospital’s attention,” Greene says.
If you’re going through insurance, compare the bill with the explanation of benefits (EOB) you received from your insurance. The explanation of benefits outlines what costs your insurance will cover. “Never pay any bill until you get that,” Donovan says, “and then you just compare that amount on the EOB to the amount you’re being billed. If those amounts don’t match ... you should start making phone calls.” There’s no hard and fast rule on who to call first — your insurance or the provider’s billing department — but make sure you’re bringing up the issue with both of these departments, Donovan says. Even if your insurance denies claims for medically necessary tests or procedures — as recent ProPublica reporting found is common at Cigna — you should appeal the rejection.
Fisher recalls a patient who came to PatientRightsAdvocate.org to help dispute a $15,000 EpiPen charge from a hospital visit. Once the patient alerted the hospital of his insurance carrier, the price dropped to $4,900 — still considerably higher than the $70 he would have spent at a pharmacy with a prescription. The patient referenced the hospital’s price list and found the maximum the hospital could charge patients for an EpiPen was $600 without insurance, and $300 if he used his insurance. “He wrote a letter to his insurer and the hospital showing that they way overcharged him,” Fisher says. “They both wrote back saying that there must have been a glitch in the system.” The patient’s bill for the EpiPen was eliminated, Fisher says. Referencing the fair market price listed at Healthcare Bluebook and Fair Health Consumer can also be a useful negotiating tool to lower your bill.
Can I get on a payment plan?
Hospitals are usually willing to work with patients to receive any amount of a bill, Donovan says, so you should negotiate a payment plan if the lump sum is too large after checking for any errors. Consider all of your other expenses before agreeing to a monthly payment amount. If the billing department employee you’re speaking with isn’t receptive to your needs, Donovan suggests ending the conversation and calling back in a day or so — you might get an employee who’s more amenable. (This advice works for any of the interactions you may have with the billing department.) Again, ask to see information about financial aid as well because you likely qualify for some amount of assistance.
The nature of the American medical system requires a lot of patients: ensuring they’re staying in-network, double-checking bills for errors, advocating for low-cost care. Organizations like the Patient Advocate Foundation and Resolve work with patients to negotiate their bills with hospitals, so don’t be afraid to ask for help.
“Patients have the right not to be discriminatorily overcharged,” Fisher says. “No one should accept medical debt.”
