Days before Theresa Schmotzer’s outpatient surgery, the hospital called, demanding roughly $3,700 upfront.
She had waited months for the procedure. The caller was insistent, Schmotzer recalled, and she feared the surgery would be canceled if she didn’t pay. But the number couldn’t be right. Her maximum out-of-pocket for the year was only $3,500.
While Schmotzer, an occupational therapist in Arizona, was preparing for surgery, she was also becoming a billing investigator.
At the moment patients are most vulnerable—sick, in pain, anxious, or facing a scary diagnosis—they are handed a digital pen and asked to accept full financial responsibility for costs no one has disclosed. Cynthia Fisher, founder of PatientRightsAdvocate.org, calls it signing a “blank check” for care.
In almost any other part of life, that would be unthinkable. In American medicine, it is routine.
For planned procedures, knowing the price is part of informed consent. Patients have more power than they realize to insist on it before they sign.
No One Had an Answer
Schmotzer told the billing office she wanted to wait for her explanation of benefits from the insurer. The hospital said it needed the money up front.
So she went looking for a number herself. She called her doctor’s office and got the Current Procedural Terminology (CPT) code—the standard billing code for her procedure. She gave it to her insurer, Cigna, and asked what she would owe. They couldn’t tell her. She called the hospital with the same code and her insurance details. They couldn’t tell her either.
“How the hell do none of you know what you’re going to charge somebody that’s coming in the door?” she remembered thinking.
She had the code and the coverage. She had called everyone involved. What she didn’t have was a price, and on the morning of surgery, she was still trying to find one.
The hospital had estimated the procedure at nearly $29,000 and wanted about $3,700 of it upfront. Weeks later, her actual explanation of benefits from her insurance showed she owed just $751.
The hospital’s billing office had been confident enough to demand payment. Its estimate was off by thousands.
Why No Number Tells the Whole Story
There’s a reason the hospital couldn’t give her a firm price. A patient may think she’s buying one procedure at one place. In fact, the bill can split among the hospital with its various facility fees, the surgeon, the anesthesiologist, the lab, the pathologist—each charging on its own.
Some of those bills come from in-network providers covered by insurance. Some of those bills come from out-of-network providers, like an anesthesiologist, that are not covered by insurance. If you don’t know to ask, you won’t know which is which until the bill arrives.
Caitlin Donovan, senior director at the Patient Advocate Foundation, remembers a patient who checked whether her hospital was in-network, meaning it had agreed to her insurer’s rates, before delivering twins. The babies came early. Then came the bill: $30,000.
The harder problem is figuring out what you will owe in the first place. Prices vary wildly, and Schmotzer came to see that as the problem itself. “It’s like going to the store and buying milk,” she said. “Everybody’s in line with a gallon of milk, but everybody pays a different price for milk.”
Even when a price is available, it is rarely your price. A single billing code “is not necessarily sufficient for giving precise out-of-pocket costs,” a spokesperson for AHIP, the insurers’ trade group, told The Epoch Times.
The final amount depends on your specific plan, how much of your deductible you have already met, and whether anything changes during the procedure, such as extra time or an unexpected finding.
Health plans offer online cost estimators and call centers, but these are only rough guides. The real number often isn’t known until after the care is delivered and the claim is processed.
Still, Schmotzer had supplied much of the information insurers say they need. She had the billing code, and knew both the hospital and the surgeon. She called her insurer more than once. A rough estimate should have been possible.
She never got one.
The Blank Check
Fisher’s organization pushes for prices to be posted before care is delivered. She said the current setup keeps patients blind to the cost, then blindsides them with the bill.
The trap, she said, is the signature. At the point of care, a patient may be handed a digital pen and asked to sign, often without a form to read or a copy to take home.
“We are forced, in order to get care, to sign a blank check,” Fisher said. What the signature commits patients to is full financial responsibility “to pay whatever they choose to charge you.”
The demands are coming earlier. Fisher’s group has seen prepayment requests ranging from $250 for a dermatology visit to $30,000 for brain surgery. Hospitals, she believes, count on some patients not pursuing refunds when estimates run high. “They’re banking on that,” she said.
Hospital finance leaders dispute that. Any overpayment belongs to the patient and should be refunded promptly once the account is reconciled, Richard Gundling, senior vice president of professional practice at the Healthcare Financial Management Association, told The Epoch Times.
Most hospitals have refund processes, Gundling said, and audits help enforce them. Asked whether hospitals count on patients not pursuing refunds, he said: “I have not seen that at all.”
Schmotzer felt that weight directly. A widow raising teenagers alone, she spent the days before surgery juggling calls and research. “It’s overwhelming,” she said, “probably overwhelming for most people trying to manage everything.”
Washington Is Starting to Notice
Federal regulators count it as one of three options under review and have finalized none. So the hospital and insurer groups, at odds over who’s to blame for the current mess, point to the same solution and wait on Washington to require it.
How to Push Back Before You Pay
These steps apply to planned, non-emergency care. Never delay urgent treatment to shop for prices. But when you have time, treat cost as a normal part of deciding on care.
The golden rule, said Adria Goldman Gross, a medical-billing advocate who once worked inside the insurance industry: “Whatever they tell you, get it in writing.”
Dr. Virgie Bright Ellington, a physician and author who trains billing advocates, advises patients to ask the surgeon for the planned CPT code, then call the insurer to learn exactly what it will pay. A useful benchmark is the Medicare rate; commercial plans often pay roughly twice that. It’s the figure Schmotzer looked up the morning of her operation.
With those codes in hand, Gross and other advocates recommend asking:
What CPT or Healthcare Common Procedure Coding System (HCPCS) codes will be billed?
These are the standard billing codes for a procedure. Without them, no one can look up a price, so the codes are what unlock every other answer on this list.
These codes unlock price estimates. Without them, it’s almost impossible to get accurate answers.
Are the facility and every clinician involved in my network?
A hospital can be in your network while the anesthesiologist or pathologist inside it is not, and if someone isn’t, your plan may pay little of their bill or none of it. Ask precisely, too. “If you call and ask your provider, ‘Am I covered?’ that’s not the right question,” Donovan said. “You want to ask if you’re in-network.”
Could the bill change if something additional is found or done during the procedure? The estimate covers the planned work. If the surgeon finds and removes a polyp, or the operation runs long, new codes get added and the price climbs.
How much of my deductible remains, and what coinsurance applies?
What you owe depends on where you stand in your plan. Until your deductible is met, you may pay the full negotiated rate; after it, you still owe a share of each bill, called coinsurance.
What Is the Cash Price? What is my insurer’s negotiated price? Sometimes paying cash is cheaper than billing insurance, so ask for both and compare. Both the hospital and the insurer can be pressed for numbers, Fisher said, though neither may hand you a final personalized figure. The American Hospital Association cautions that cash payments typically don’t count toward your deductible or out-of-pocket maximum, so paying less now can cost more later.
Is Prepayment Required? Hospitals increasingly ask for money up front, but it’s rarely mandatory. Knowing whether it’s truly required tells you how hard you can push back.
If I Overpay, When and How Will I Get a Refund? If your prepayment tops the final bill, you’re owed the difference. Ask how and when it comes back, so you’re not chasing it months later.
Ask for the estimate in writing, along with the name of the person who provided it and a reference number.
Where to Look for Help With Pricing
A handful of tools can get you into the right range before you call:
Your insurer’s online cost estimator
The hospital’s list of shoppable services
PatientRightsAdvocate.org’s hospital-pricing tools
FAIR Health Consumer
Turquoise Health
It’s good to know what they can and can’t do.
“They’re built for comparison shopping,” Bruce Telkamp, a health insurance veteran with more than 25 years of experience and founder of the cost-comparison site HealthPocket, told The Epoch Times. “They’ll show you the typical price for an MRI or a colonoscopy and whether a quote is reasonable.”
What they can’t do is tell you your bill. They don’t know your specific plan, how much of your deductible remains, your coinsurance rate, or the negotiated contract between your insurer and the provider. For that, you still need to confirm the codes, network status, and your expected out-of-pocket share directly with your insurer and the facility.
Schmotzer’s advice to anyone pressured to prepay: “Don’t.” First, find out what you’re actually expected to owe.
It Wasn’t Even Necessary
The morning of surgery, still hunting for a number, Schmotzer found one herself. She entered her billing code on PatientRightsAdvocate.org and saw an estimate of about $751—the very figure her insurer and hospital had been unable to provide. She went ahead with the operation.
Then came the part that still stings. The surgery was meant to remove a fibroid her doctors had seen on imaging. Once inside, the surgeon couldn’t find it. “It was all for nothing,” Schmotzer said. “It wasn’t even necessary.” It still cost her about $751.
She knew more than most patients. As an occupational therapist, she understood CPT codes and how to push for answers. Yet she still spent days fighting for basic information that should have been given to her upfront—for a procedure she ultimately didn’t need.
“I’m utterly disgusted with this current system,” she said. “It doesn’t serve its customers.”
Asking what care will cost isn’t difficult or rude. For planned procedures, it is the most basic form of consent—and, as Schmotzer learned, the number is usually there to be found.