The medical bills come fast and furious in my house—$538 for the monthly insurance premium, $390 for an MRI to diagnose a running injury to my knee, $150 for a recent trip to urgent care.

My 6-year-old son and I both have pre-existing conditions, including asthma. The steroid inhaler my son needs to use every day has a $250 co-pay until our deductible is paid. That $150 urgent care visit last month found I was in the earliest stages of pneumonia. We don’t have a choice to forgo medical care due to cost, because it could literally cost us our lives.

In 2016, I filed my taxes and claimed an affordable-for-me $6,790 in medical expenses with insurance through the Affordable Healthcare Act (AHA). In 2018, I filed taxes in a state of near panic, claiming a whopping $24,365 in medical expenses through the AHA—same insurance company with no major illnesses, surgeries or hospitalizations that year. It’s an increase of nearly 259 percent.

And I’m not alone. In 2018, Americans spend a collective $3.6 trillion on healthcare or about $11,172 per person. About 20 percent of  working-age, insured Americans reported having a hard time paying their medical bills to the point it caused serious financial challenges, according to a 2016 survey by the Kaiser Family Foundation and the New York Times. (The survey is Kaiser’s most recent on the subject.) Challenges include being able to pay for food, clothing, and basic household items, or being forced to work additional hours or take on additional jobs. For the uninsured, that number spikes to 53 percent.

“The biggest barrier is that things cost too much,” says Caitlin Donovan, a medical billing expert and spokesperson for the National Patient Advocate Foundation, a non-profit that advocates for affordable, quality healthcare for people with chronic, debilitating or life-threatening illnesses.

“What’s hard about health care is that it’s unpredictable,” she says. “Nobody is saying I’m going to get cancer next year so I’m going to make sure my preferred oncologist is in network.”

But there are several things you can do to avoid or reduce massive medical bills, and potentially save yourself hundreds, if not thousands, of dollars without sacrificing necessary medical care.

Here are five things Donovan recommends:

1. Carefully consider your health insurance options

Whether you are insured through an employer or the AHA, carefully compare your options to make sure you aren’t consigning yourself to a year’s worth of financial headaches.

The cost of your premium, or the amount you pay each month for your insurance, should be weighed against the plan’s deductible, or the amount you pay out of pocket before the insurance company pays. So a low monthly premium with a high deductible could cost you more in the long run.

If you have pre-existing conditions, do your homework before signing up with a plan to ensure that your doctors and specialists are in that plan’s network, which will save you money, and that the plan’s prescription drug benefits cover the medications you take regularly.

Most major insurance companies have a website that lets you look up whether a certain doctor is in network, but Donovan recommends calling the provider directly to double check, especially if it’s a specialist you see throughout the year.

2. Stay in network for medical care whenever possible

All health insurance plans, including Medicaid, have a network of providers and facilities included in their coverage. If you see a doctor in that network, they bill the insurance company and you are left paying a smaller amount, such as a co-pay. But if you are treated by a doctor not in your network, you could be on the hook for the full cost, including the doctor’s office visit fee and any tests or medications you received.

That includes hospitals and the providers that work there.

Even if the hospital is in your network, their providers might not be, meaning your insurance coverage may not extend to the bills charged by the doctors who treat you, which could include out-of-network physicians, anesthesiologists or surgeons. It’s a practice called “balance billing” or “surprise billing”and it costs Americans thousands of dollars.

You can try to avoid using out-of-network providers in a hospital setting by making it clear to every doctor and nurse that you see that you only want to be treated by an in-network provider.

Some patients, Donovan says, even resort to putting up a homemade sign outside their emergency room area or hospital room saying “Do not enter this room unless you are in network.”

While it’s not a guarantee, Donovan says, “it’s been effective for some people I’ve talked to.”

3. Watch your medical bills closely for errors

Donovan kept close track of her medical expenses during her third pregnancy.

“One of the things I stumbled across was figuring out how much mistakes would have cost if I hadn’t have caught them,” she says. “It was over $500.”

For example, after the birth of her son three months ago, Donovan says she was charged $250 by one provider. She paid the bill, but upon closer examination realized that provider, who was in her insurance network, never even tried to bill the insurance company. She shouldn’t have been charged at all and it took her eight months to correct the error and get a refund.

“I’m a medical billing expert and I still made this mistake,” she says, adding that she caught another bill that didn’t line up with the explanation of benefits, which would have added $100 more in overcharges.

“If you’re not paying attention to it…you’re going to end up paying more money,” she says. “I’ve never seen a mistake work out in favor of the patient.”

4. Negotiate everything

While you can never be sure if the person on the other end of the phone will have a sympathetic ear, it is worth calling your healthcare provider if you get an unexpected or larger-than-expected bill. First, make sure your insurance has paid for everything they are responsible for, Donovan says, then check the Healthcare Bluebook, an online medical care guidebook that lists reasonable rates for a multitude of medical services.

“Then start working directly with your [healthcare] provider. They have an incentive to work with you because they need to get paid,” she says. “No one is crazy enough to think someone could get a $30,000 bill and pay it in full within 10 days in cash.”

Things to ask for include:

  • If they will take the reduced rate paid by Medicare or Medicaid
  • If they will take the rate quoted by the Healthcare Bluebook
  • If they will give you a cash discount
  • If they will set up a payment plan to spread out payments

Also talk to your healthcare providers about your financial situation and any concerns you have about medical bills, even if it makes you feel uncomfortable.

“It’s hard to talk about healthcare, it’s hard to talk about you finances, but you should do it with you provider because they can help you,” Donovan says. That help can include giving you samples of expensive medications or altering your treatment plans with a lower cost option that still gives you the treatment you need.

5. Don’t pay the collections agencies right away

“When you’re dealing with collections the first thing to do is to not pay the bill,” Donovan says. “If you pay a bill to collections, if something is in collections, that means you are claiming it and owning as yours.”

This may sound counterintuitive, but it can buy you time and save you money to avoid paying a bill even after it goes to collections. You may still have to pay your bill in the end, but there are some things you can do to avoid paying a large lump sum.

First, know that the three major credit bureaus have agreed to give consumers 180 days to resolve medical debt before it goes on your credit report. That doesn’t stop your bill from going to collections, but gives you time to resolve it, or at least delay it, before your credit takes a hit.

You can  validate the bill by telling the collection agency the collection agency you want to dispute the debt. They then have 30 days to mail you documents verifying your medical bill and what the bill is for. If they can’t or won’t do that, they have to stop trying to collect.

You can also try to negotiate payments with the collections agency by asking if they will set up a smaller payment plan or even reduced payment plans.”

Donovan has some additional tips for people looking to lower or avoid paying large medical bills:

Understand medical billing jargon, including co-insurance, deductible and copay, so you are clear on what you are billed and what you are responsible. Check out the HealthCare.gov glossary for more information on these topics.

Shop around for prescription drugs. Work directly with the drug manufacturer or pharmacy for a discount or consult GoodRx.com to see which pharmacy in your area sells your prescriptions for the lowest cost.

Use a primary care physician as your first line of defense. Donovan says there is a trend for patients to skip the primary care provider and head straight to a specialist, but the latter may charge hundreds of dollars more for care your PCP could also give.

Avoid potentially unnecessary testing. Ask your provider if it’s really necessary for X-rays, bloodwork, ultrasounds, or other testing. These services might not be medically necessary and can add significantly to your bill.

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