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My partner and I have recently had a few medical-type procedures (dental, veterinary), at small private practices, that we pay at least partly out-of-pocket. In each case we were given advance estimates, and then a significantly higher bill after the procedure was over. For example:

  • My partner gets some dental work done. This will be partly paid by insurance. Initially, she's quoted an out-of-pocket estimate of about $900. Some time after the procedure is scheduled, she gets a revised estimate of about $1,200. Months after the procedure occurs, she gets an added bill (saying insurance didn't pay as expected) for about another $150. (So: a 33% increase, and then another 16% increase.)

  • I schedule a veterinary checkup for our cat. This will be paid entirely out-of-pocket. On the phone I'm quoted an estimate of $67 for the checkup. After the checkup, in which no outstanding issues were detected, I was given a bill for $334. (Roughly a 400% increase from the estimate.)

To highlight some aspects of the cases I'm talking about: These are not emergency/ER procedures. These are elective procedures or other private medical-professional visits. There are no advance consent forms for payment being signed in regards to the specific procedures -- other than a general assignment and release for coverage on initial entry to the practice.

So, is there any room for pushback in these kinds of cases of medical-type inaccurate estimates? I think with car repairs I could say in advance something like, "If the bill is more than $X, don't do it, call me first," and that would be honored. In none of the cases above does the issue of more work or a higher bill come up while the procedure is happening. And generally the practitioners don't want to answer direct questions about billing; they refer that to their office staff at a later time when they're not in the conversation. Maybe there's a particular dollar or percentage cutoff below which we shouldn't worry.

If it matters, I live in the big city (NYC). On the other hand, my own father is a very old-school farm veterinarian in another state, and his business advice was the opposite -- if you give an estimate, you need to stick to it, even if it costs you money due to an error. So I'm getting very mixed signals.

What's the best practice, or how much flexibility is there, for negotiating or pushing back against these surprise medical-type bill increases?

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    These are two very different situations. In the end, it's your responsibility to verify what your insurance will and will not cover, not your dentists. 33% is a lot, but not that much. The veterinary estimate does not sound like a good-faith estimate. The checkup was probably $67, but they probably left out routine lab work that could raise the price.
    – chepner
    Aug 14 '21 at 19:35
  • @chepner: (1) But our dentist (and others before this one) said exactly the opposite, that they'll handle all the insurance advance approval. Should we assume they're all lying? (2) How can we know about the "routine lab work" when no one told us about it or priced it in advance? Given that was very much obscured/not mentioned at any point as a separate thing, what resolution is there now afterward? (that's the essence of the question, of course) Aug 14 '21 at 21:44
  • It's not the opposite. The dentist is just filing the paperwork and getting paid directly; their estimate is based on what they think your insurance will cover before actually verifying that information. I'm agreeing with you with regard to the veterinarian: I would ask for an itemized bill, and ask them why the additional costs were not mentioned originally.
    – chepner
    Aug 15 '21 at 12:40
  • @chepner: No, the dentist has filed and gotten prior approval from the insurance company (before the procedure), and then changed how much we get billed later. Aug 15 '21 at 13:35
  • Then the $150 isn't really something you can blame your dentist for, if it's due to something your insurance company decided.
    – chepner
    Aug 16 '21 at 13:25
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These may be cases of open price contracts in which case I think you do potentially have room to make a good faith pushback. According to law professor Christopher Robertson on An Arm and A Leg Podcast, an open price contract is not a blank check.

Ask for an itemized bill and investigate typical prices in your area using https://www.fairhealthconsumer.org. I don't know if that will have all dental procedures, but it might. It won't have vet procedures.

Check out Never Pay the First Bill for more tips on negotiating medical bills.

There's no harm in asking for what you want and trying to negotiate. Just be kind and polite.

One suggestion I've seen to avoid this type of problem in advance is explained here, though it is specially for ERs.

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  • Thanks for this, but: In none of cases from the question were informed consent forms ever signed... Aug 15 '21 at 2:45
  • Moreover: The advice in the first link sounds sketchy/hypothetical. It doesn't look like it's ever been legally tested. E.g., from sublinked NY Times Article: "Such efforts are best applied only in emergencies — where federal law requires hospitals to stabilize patients and not toss them into the parking lot... However, patients who refuse to sign documents or try to alter them in nonemergencies — say, at a doctor visit or for elective surgery — could be refused service." Aug 15 '21 at 2:48
  • .... And (on top of no consent forms in the first place) non-ER "doctor visit/elective surgery" is precisely the situation(s) in the question at hand. Even the linked page itself says (at bottom): "*Legally, we can’t guarantee this will work." So unfortunately I don't think this answer addresses the case of the question either before or after the procedures. Aug 15 '21 at 2:51
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    These are all good points and I agree with you that the consent suggestion does not actually help your specific case. I've edited the answer to reflect this. I think there could still be value in looking at fairhealthconsumer.org. I have used it in the past, though always for medical and not dental procedures. Your question was "is there any room for pushback in these kinds of cases of medical-type inaccurate estimates?" Are you asking this in a legal sense or just norms? If you feel this is unfair treatment, then trying to negotiate makes sense.
    – avintenus
    Aug 15 '21 at 18:40
  • Thanks, my intent was norms of negotiation and exactly how. Aug 15 '21 at 19:53
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You're right that different cultures will treat an 'estimate' differently - your NYC estimates seem to be mere estimates with no obligation attached to them.

Call the front desk, and ask if they have time to go over your bill. Then just lay out the facts as you have here: "Can you explain..." "How can we avoid these revisions in future visits?"

Medical offices are perfectly able and willing to abide by a rule, e.g., "call me if there is a change from this estimate." They are perfectly willing to forgo a procedure after the patient asks "would that be an additional charge?"

The provider's responsibility is to get consent for every procedure; the patient's responsibility is to ask what procedures cost before giving consent.

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  • Thanks for writing this. But I'm afraid your 3rd paragraph doesn't make much sense to me: (1) We're right there as the procedure happens, why/when would such a call take place (contrast with auto repairs)? (2) We find ourselves unable to detect exactly what specific hand-motion is part of the originally-discussed procedure, vs. what is a brand-new procedure, to know to ask or consent about it. Aug 14 '21 at 21:39
  • You can ask about costs as soon as your hygienist removes her fingers from your mouth: "This fluoride treatment that you just recommended, does it cost extra, how much and what are the benefits?" With the vet: "What are today's treatments and are they all covered by your previous estimate of $67?" If the provider doesn't want to talk costs, say "I can wait for your staff to explain it to me." Aug 14 '21 at 22:23
  • The first one, nothing is ever "recommended", it's just "now I'm doing this", unclear if it's a subset of another procedure or not (often with instruments in mouth). The second one, maybe. Aug 15 '21 at 2:35
  • Also e.g. at the vet in this case I'd already waited in a filled waiting area 4 hours past the appointment time, so I seems possible if I said "I can wait", they might have just said, "then I won't be able to see today". Aug 15 '21 at 2:54

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