This last part of my series is a bonus post! It has to do with handling those rare cases where you DO have to go see a professional. I do as much self-testing & holistic healing as I can, but some things (e.g. yearly dermatology visit for my moles) or when I do something stupid (e.g. splitting open my head…I’m good at this kind of stuff) then I have to go see a real doc. Given we carry a $10,000 deductible on our insurance and most of what I need (e.g. dermatology) is not included in “free” preventative care, I try to do as many of these things as I can on my own $$. Also often I can get significantly cheaper pricing by going “direct” than by taking the procedure through my insurance (seriously…and I’m not the only one who’s discovered this!). For this reason alone cash-pay is usually my #1 choice for anything “non-catastrophic”.

Negotiating this mess is non-trivial. I’ve had my good share of these kind of incidents over the last 4 years so I figured I would share what I’ve learned along the way.

Shop Around, Shop Around

You've GOT to shop around if you're cash paying for medical care

You’ve GOT to shop around if you’re cash paying for medical care

If there’s one tip I can give you that trumps all others when it comes to self-pay medical care it’s to shop around. You will be surprised….no scrap that…you will be ASTOUNDED at the differences in price for standard procedures across the board. There is no (NONE) standardized cash pricing on healthcare in the US, so there are literally no limits to what you can be charged. I’m not talking brain surgery here (although I’m sure price varies alot there too), I’m talking run-of-the-mill straight-forward standard procedures. Here’s my 5-step process for getting the right price:

Get a fair range before you get a quote

Research fair range before you get a quote


Double-check your ranges here

  • Get An Estimate Of Fair Pricing: If you’re going in for a new procedure and have no idea what to expect, it’s worth checking the Health Care Blue Book (they also have an app) for “fair” pricing on standard procedures in your area. This is not a definitive guide, but it sure can help to narrow your range. If what you need is non-critical you can even use this resource to check cross-country for potentially cheaper spots along your RV travels. Fair Health Consumer offers a similar price comparison list. I use both before I ever get a real quote from a doc.
  • Narrow Your Selection: Once you’ve chosen a specific location Google local docs & select the ones that have the largest number of positive reviews.
  • Call Around For Cash Pricing: Call each of your selected docs and ask if they offer fixed “cash pricing” for what you need done. Often you will need to talk to the “billing department” to get this info since the front desk may not have a clue. If they can’t give you a fixed cash price, cross them off your list.
  • caution

    Always ask “Is there anyone else who might bill me?”

    Check For Additional Fees: If you’re getting surgery done ask the billing department if they cover all aspects of the surgery or if there are separate fees for facility, doctor, blood/lab-work, meds and anesthesiology. Often you will need to deal with 2-4 different billing departments to get the full picture of your costs. Also, if you’re going to have more than one doc in attendance for your surgery you may well be charged for each one individually. Ask and confirm.

  • Ask For Extra Discounts: Ask if you can get a discount for pre-paying the procedure. Often there is a discount for cash services and an additional discount for pre-payment.

Here are two personal examples:

1/ Dermatology – every year I shop around for a dermatologist to give me the once over and remove any suspicious moles (I’m a dermatologist’s dream when it comes to these). In this case I’m looking for cash pricing for a skin-check PLUS mole removal PLUS sending it out for pathology. I specifically ask the office if they have a fixed cash price for all 3 of these in one. I called 5 well-rated spots in Palm Springs when I got here a few weeks ago. Three of these could not give me a fixed price (one couldn’t even give me a range!!), but one of them had a fixed $350 price for the three-in-one. I know from experience that that’s a good price so that’s who I went with.

2/ Surgery – In 2012 I needed some very standard surgery done. I called around to 6 hospitals in San Diego and got prices varying from $2,000 to $12,000 (and that last one was just an estimate!) for the exact same procedure. Delving into the details revealed I would need to pay a surgery fee (which included the doctors fee and all blood/lab-work), an anesthesiology fee and a facility fee. Two of these gave me an additional 20% discount for paying up-front. As a side-note, I had to take some prescription meds as part of my surgery. Calling around to 5 different pharmacies gave me 5 different prices on the exact same meds (in the end Costco was the winner). It was a bear to figure out, but I saved thousands (literally) by taking the time to wade through these calls.

For Minor Issues Go To Urgent Care Clinics

Next Care is one of thousands of Urgent Care clinics across the country

Next Care operates in 8 states and offers a discount program

One of the costliest things you can ever do is go to the emergency room. Prices seem to sky-rocket to around 10 times the norm whenever you do. There are times you can’t avoid it, but for the minor issues (flu, minor injuries, general illness etc.) look for an Urgent Care clinic. There are ~9,000 of these all over the country and they are fairly inexpensive. Most of these clinics will have fixed prices to see a doc (~$100-$200) and they are “walk-in” ready. Some clinics even have “nationwide” networks & pricing programs.

US Healthworks manages 145 Urgent Care clinics in 16 states

For example USHealthCare has clinics in 16 states and offers special discount coupons for cash-pay patients. Next Care has clinics in 8 western states and offers special discount pricing on office visits & procedures if you buy their $50/year Value Care program (if you have kids that often need visits or you’re the clumsy type this kind of program could make sense for you). We went to an Urgent Care clinic in Kentucky in 2010 when I suspected we had Lyme Disease. It cost $100 to see the Doc and another $4 (see below) to get the antibiotics to treat us. Easy and inexpensive.

Negotiate, Negotiate, Negotiate

Be tough in your negotiations

Don’t accept the first bill the hospital sends you. Negotiate, negotiate, negotiate!

What if you end up with a bill where you didn’t do the due diligence? In 2011 I ended up in the emergency room in Astoria, OR after splitting my head open on the RV slide (a classic Nina moment). As a result of the fountain of blood spewing out of my skull I wasn’t thinking straight, didn’t go to an urgent care, accidentally gave them my insurance card and didn’t ask up-front about cash pricing. Three weeks later, the $1,500 bill I got for the 15 mins I spent in the emergency room while they put 2 staples in my head nearly caused me to split the wound open all over again. So, I called and told the hospital I couldn’t pay. After 30 minutes of negotiation (“I want to pay you now, but I just can’t afford this bill”….”If this goes to collection you won’t get your money for years. Give me a cash price I can pay now”…”Surely you can do better than this. Let’s settle this now and get it off your accounts” etc. etc.), I got the bill reduced by 50% if I agreed to side-step  my insurance and pay the hospital directly on the spot. Still bloody expensive (pardon the pun), but a lot better than the first price.

P.S. For those of you who hate the thought of direct negotiations there is also the option of hiring a professional Medical Billing Advocate to handle your bills for you. For a price and/or commission of the savings, these folks will work directly with hospitals, find errors and reduce out-of-pocket costs. Definitely worth it if you’re facing huge bills and don’t know where to turn.

Sub-Note: Aren’t Emergency Care Costs Now Protected By Obamacare?
One of the new provisions in the ACA law is that Emergency Care must be treated as “in network” by all insurers, even if you end up in a hospital that’s not part of your provider network. This can certainly save some $$ on the insurance bill, but there is an important caveat -> the law doesn’t protect you from “balance billing” from out-of-network hospitals if they decide your insurance did not pay enough. Even worse, these “balance bills” don’t count towards your deductible or out-of-network caps, so you could end up with thousands of additional $$ that you need to pay on your own dime. There are only a few states in the country where balance billing is illegal. So, be aware.  You may still need your negotiation skills if you end up in the emergency room!

Go Abroad, Go International

Should you go get your dental work in Mexico?

Should you go get your dental work in Mexico?

For those of you who’ve never traveled abroad the thought of getting medical care outside the US can be scary. However, the truth of the matter is that medical care can be both excellent and inexpensive in foreign countries. Many countries cater to Medical Tourism (for example, the large hospitals in Thailand -> I would not hesitate to use these) and specialize in fixed pricing for even complicated procedures. You’ll need to spend alot of time doing due diligence and research if you chose this route, but it can save you a ton of $$. Last year Paul and I went to Mexico for our dental work and got some basic work done for ~30% of the price we would have paid in the US. This will likely be our choice from now on. I haven’t (yet) found a primary care doctor or dermatologist I can trust in Mexico, but it’s on my list for the future. Also, for folks on prescription meds you can often save hundreds by buying them across the border.

Additional Links
Just a few, additional cost-saving links:

  • The $4 List -> If you’re on prescription meds or being offered a med and don’t know about the $4 List, go check it out. Using this list can save you hundreds. Walmart, Walgreens, Costco etc. all have them. Costco even has a special prescription price list for cash-pay patients which saves $$ on meds outside the $4 list. Bottom line -> if you’re on meds shop around!
  • County Health Departments -> If you’re uninsured or your insurance doesn’t cover it many County Health Departments across the country will offer very low-cost vaccinations/immunizations from childhood through to travel or flu. For example San Diego offers this service for $10 regardless of how many shots you get. Thanks Doug for this tip.
  • Dental Schools -> If the thought of going to Mexico for dental work works makes you shudder, you may want to look into Dental Schools that offer free or very low-cost dental care all over the US. Be ready to spend some time here (these are often multi-day visits), but if you plan ahead they can be an outstanding deal.
  • GoodLuckDuck -> My blogger buddy Roxanne has excellent, additional links on healthcare for poor people.
  • The Truth About Health Care -> This is a rather “sensational” site, but does contain some gems of information especially regarding hospital billing and prescription medication. It helped me understand the financial side of healthcare in alot more detail.

That’s about all I can come up with for this series (at least for now). Hope it’s been educational & that I’ve encouraged you to take charge of your health & save some $$ in the process.

51 Responses to Self-Medical Care Part III – Negotiating Doctors, Hospitals & Clinics With Cash Pay

  1. You are amazing. So thorough and then generous with taking your time to share all of this information in such an organized, easy to understand manner. I continue to be impressed with your blog on so many levels! -Linda

  2. Dave'n'Kim says:

    NIna and Paul,
    I’ll be one of many applauding you for this excellent article and series! May I ask if you might be able to do any article regarding choosing Health Insurance? We have none. I’m ignorant of latest (and newly incoming) requirements.Today for a dental checkup (at low-income-discounted SoCal CHC Clinic chain), I picked up a leaflet saying “As of Jan 1, 2014 all US citizens/residents must have some health insurance… if not, you’ll have to pay a fee… $95 per adult for 2014…”. When I asked them if for any visit, instead of my usual $56 for 3-monthly ‘teeth-scraping’ this meant I’d have to pay $95+ (additional? or instead of?) they didn’t even know, so they are as confused as I am!

    • libertatemamo says:

      Health Insurance is a whooooole massive subject of its own. I actually have a post planned on how the new health care law (ACA, or you might have heard of it as “obamacare”) is impacting our choice of RV domicile. I won’t be able to go through all the details here, but for what you need to know -> the new law requires everyone to have insurance in 2014 (or you pay a penalty). That does NOT apply to dental work and there ARE some exemptions especially for lower-income folks. My best advice is to read through these links:

      1/ : This is the main website for the federal health insurance exchange. You can read about the law and search for insurance plans here.
      2/ Obamacare 101 – What To Know If You Opt Out Of Buying Health Insurance : This is a good article about exemptions & what to expect if you decide to forgo health insurance.
      3/ The Affordable Health Care Act – How It Works : A good write-up from a fellow RVer about the main provisions of the ACA law.

      Hope that helps!

      • Luna says:

        Great series – thank you so much! I realize it’s personal, but… I’m very interested in what you are finding in the ACA/domicile area. I had been going to domicile in SD (yes, I’m needing to choose now, of all times!), but after looking up 2014 insurance options (and reading that many plans don’t count domiciled folks as residents there), it’s not looking like the best choice all of a sudden.

        • libertatemamo says:

          I’ve actually been collecting my data for a detailed ACA post, but the short of the story is that we will be switching domicile out of SD to another state sometime next year. Sadly, the options in SD for pre-Medicare have dwindled to almost nothing. Our current insurer (Coventry) is not participating on the exchange and the 3 who are (Avera, Sanford and Dakotacare) are not offering any kind of useful nationwide plan. Only Avera is offering PPO, but their network is near non-existent. If you’re starting to look at domicile now I would recommend FL or TX.

          So, that’s a little preview of our point of view of the whole deal. I have a more detailed post coming soon.


      • Luna says:

        I can’t nest this below your reply to my reply (whew), but thanks for the “preview” of your ACA thoughts. Will be very interested to read more on that and your domicile move, if/when you choose to post about it. In the meantime, I’m leaning toward TX (of TX or FL). Either of them will give me a bit of an identity crisis, but…. I’ll just have to get used to it, I guess. (< –she drawls).

        • libertatemamo says:

          Texas is currently top of our list too, although we haven’t finalized it yet. BCBS is offering a PPO plan on the exchange there which looks like it’s got strong networks and decent out-of-network caps (an important detail). Also BCBS will accept Escapees address as a legal domicile in TX. We may still consider FL (or even another state), but so far TX is looking very strong. We’ve got until Oct 2014 (when our current plan expires) to figure it out.


  3. Bob Martel says:

    Hi Nina, This is fantastic! Would you consider adding a “button” at the top of your blog page (i.e., near the “About Us, The Journey, etc..” links) linking to these three excellent healthcare articles? It would be a real asset to those of us who might want to refer to them in the future. Thanks, Bob

  4. Donna K says:

    Excellent information Nina. Folks might also want to know they can question the doc on what tests/procedures are absolutely necessary. Sometimes there might be a less expensive alternative to what the doctor initially recommends. Like you have pointed out so well, we need to be our own health advocates.

  5. Nuttmann Robert says:

    Excellent post. You invested a lot of time to put it all together. Thanks. It would be nice if the ACA addressed some of the problems Dr Belk talks about.

    • libertatemamo says:

      Yeah, I feel quite strongly that a big part of the healthcare issue is lack of price transparency, and sadly the ACA doesn’t address this. Sure wish hospitals and doctors would be forced to publish their costs. It would promote more consistent pricing and give consumers so much more choice.

  6. We do want to thank you for sharing how you got a better price by paying cash the last time we were together, because we remembered that when I needed a root canal. We have dropped our dental insurance and so when I went for the root canal we asked about a cash price. It saved us money by paying in real cash dollars. So thanks for the tip:)

  7. Frank says:

    All I can say is WOW and thank you. One of your more informative posts (among many). This will be very helpful to me as I am floating in the void of being retired but several years away from being eligible for Medicare.

    • libertatemamo says:

      I think more and more people are finding themselves in that spot. Lots of pre-Medicare folks are now buying high deductible insurance plans (or even forgoing insurance altogether) so the demand for cash pay is only going to grow. Hope this helps you negotiate the landscape!

  8. flyfishnevada says:

    We’ve discovered a little trick. It seems we can choose not to have the doctor/urgent care/hospital bill the insurance for care but still submit the bill ourselves and the insurance company will count it against our deductible. For instance, my physical therapy for my back I could have paid cash and saved 50%. That was the policy but they couldn’t bill my insurance event though I’d ultimately pay for all the care until I hit my deductible. But I could have, paid cash, got a copy if the bill and sent it in to count against my deductible.

    At $250 a visit, that was a saving to me of $125 each time I went and I could’ve still gotten the $125 I paid applied to my deductible with just a little extra work of scanning and emailing the bill. YMMV but that’s a way to reduce out of pocket costs. We make a habit of always asking if we get a cash discount now. If you hit your deductible, or plan on to, you might just want to get the insurance company paying sooner rather than later and pay full price but otherwise, you can save some money.

    Additionally, no matter what the billing people say, you can usually spread payments out with no interest. Of course, they want to convince you to pay as much as possible and might even offer financing (with interest) but in many places, they have to take whatever you tell them you can afford. We owe half to doctors in northern Nevada money that we pay over time (due to my wife’s gall bladder removal and complications – she’s good to go now) but it beats emptying your savings to pay them off all at once and be left with no emergency cash.

    Thanks for the great articles!

    • libertatemamo says:

      Fabulous little tip on submitting the bills against your deductible after-the-fact, even if you go the cash pay route. Never knew you could do that. I am definitely going to try that next time!
      Thanks so much for sharing!

      • flyfishnevada says:

        Can’t promise it’ll work for everyone but I don’t know why anyone would complain. You get care for less money, the doctor doesn’t have to process insurance paperwork and it delays when the insurance company will have to start paying. Seems like a win-win-win but you never know.

  9. Mike Davis says:

    Nina and Paul, these articles are really a big, big help for most people that can apply themselves to the issues. Saving money is one thing, but good medical care at reasonable prices is the real eye opener. The fact that you actually look at the bill and can easily discover discrepancies keeps people more honest. We need more of this to keep the bills in check.
    I love all of the self test links you provided.

    Great job putting this all together.
    I like the idea of the button links, but I put the links in my Med folder.
    Thanks so much.

    • libertatemamo says:

      I do find astonishing that there are so few controls over medical billing. It’s a big enough problem that there are actually professionals (Medical Billing Advocates) who you can hire to help work through errors and reduce your medical bill. I’ve always negotiated all my own bills, but this is an important resource for those who need outside help. In fact, I’ll go back and add this as an option to the post.

      Here’s a good article on this (although some of the links are outdated):
      Medical Billing Advocates Could Save You Big

      And a more recent one with more details:
      Hiring a Guide to the Medical Bill Maze


  10. Sherry says:

    Thank you Nina for what I know was a lot of your time spent in writing these 3 very educational posts. You are generous indeed. I hope “next go round” in the universal healthcare fight will include pricing transparency. That is if they EVER stop arguing about this attempt.

  11. Larry says:

    Great info and glad I’m on medicare.- except for the being old part.

    • libertatemamo says:

      Health Care is the one time I wish I were older LOL. Can’t wait to get on Medicare!

      • We’ve only been on Medicare for a short time, but are 100% satisfied thus far. If this is what they call ‘socialized medicine” I like it! When you talk about negotiating price, i don’t think anybody drives a harder bargain than the folks at Medicare.
        I hope for your and Paul’s sake they don’t raise the eligibility age.

        • libertatemamo says:

          It’s true. Medicare is actually a very aggressive price negotiator and (often) has the lowest prices for a given procedure. In some aspects this has become a problem in that some docs/clinics (e.g. Mayo Clinic) have actually stopped support of part B Medicare because they cannot support their price structure. On the positive side, however, I will often use Medicare as one of my “benchmarks” when asking for price. Typically I will ask the billing guys “How does my cash-pay price compare to your Medicare price?”. As a cash-pay patient I expect to get a discount on the Medicare price, but I don’t always get it.

  12. Awesome post, yet again! Truly inspiring. To me, you’re a combination of Ralph Nader and Clark Howard (radio commentator) offering a mix of consumer protection and information.
    I’ve requested a McDougall cookbook from our local library based on commenters’ recommendations from previous installments.
    I had no idea there were resources out there such as the Health Care Blue Book. I had discovered the $4 prescription lists. I’d been foolishly paying a $10.00 co-pay for the exact same maintenance medication (high blood pressure). I have to wonder who was “pocketing” the difference, the insurer or the pharmacy, since neither had suggested the money-saving alternative. I actually raised the issue with my employer’s HR dept., and the next time annual benefit enrollment came around they offered the option in the plan information booklet!

  13. Ann & Bill says:

    Thank you for your post. Negotiating medical cost has been much on our mind. So much to study on all the links you provided. Thank you again. Joined your blog today. We have been following for awhile now. Trapped at Cape Blanco as hosts for one more week in an awful rain storm. Though I must admit the month on a whole has been wonderful. Beautiful weather last month at Tseriadun.

    • libertatemamo says:

      This series of posts has been on my mind for a looong time, so I’m really happy I finally got them written. I know alot of us pre-Medicare folk carry high-deductible insurances and face the same challenges. Knowing what options we have helps us all.
      Also happy to hear you’ve had some good weather up until now on the coast. That’s amazing! I do miss Cape Blanco…storms and all.

  14. heyduke50 says:

    two comments – so glad you recommended a yearly dermatology visit for moles as the recent chunk taken out of my chest for an in situ melanoma says get them checked annually before they kill you… also you mentioned dental schools but also there are dental hygiene schools that will celan your teeth on the cheap (cheaper than Mexico but will take longer)…

    • libertatemamo says:

      Good tip on the dental hygiene schools! And yes, I always get checked yearly on my moles. I have ALOT of them, and it’s just one of those necessary things. I sure wish it was covered in “preventative care” however.

  15. Liz-Boise, ID says:

    Thank you for all your medical insight. I have thyroid issues & have always questioned if the regular testing is enough (like you, cold feet still….my hubby said a corpse has more heat than I do…lol). Even though I’m on the “recommended dosage”, I’m also still tired and the same as you, my doctor wouldn’t do additional testing. I’m going to do an additional test & see what it turns up…..Thank you!!!!!
    Liz-Boise, ID

    • libertatemamo says:

      Oh I definitely recommend additional thyroid testing, as well as an iodine loading test. Have a read through the website link (Stop The Thyroid Madness) that I listed in the post. I learned so much about thyroid problems from that site. It discusses testing, supplementation and different thyroid meds (for those who need them). I was very lucky in that my problems were fairly mild (apart from the “ice tong” feet LOL!) and were resolved completely through iodine level normalization, but others may need a more multi-pronged approach. Don’t accept to live with the symptoms…there are options out there!

  16. Roger says:

    There is a little to no price transparency because there is little if any demand for it from the “consumer”, i.e., the patient. Iy you ask the “expert” on health care financing who should be responsible for paying for health care their answers may very but they all have one theme in common: anybody but the patient. That is why there is no price transparency. When the government pays for your health care the doctor’s duty is to the government not the patient, kind of veterinary medical ethics. If I do what’s best for my patients am accused of “milking Medicare”. I am expected to “manage” Medicare dollars at the expense of providing best care.
    All of your recommendations are spot on as they promote a free market in health care and I applaud you all.

    • libertatemamo says:

      It’s true. Most people just expect their insurance or Medicare to take care of it and never question the real price. I believe the demand for cash pay will increase, especially with the implementation of ACA (i.e. more people buying high-deductible plans), so I am “hopeful” we’ll see more price transparency in the future.

  17. Thank you so much for yet another exhaustive and informative and helpful post. Dizzying but I have learned a lot!

  18. Terrific mention, and excellent resources. Thank you!

  19. Shirley says:

    I have to tell u..we retired and bought our own high deductible plan..our dr likes to do a comprehensive blood profile a couple of times a year…mine comes back at 425…what??…but because they submitted to insurance (which doesn’t cover it)…42.00 ….ok i can afford that…It’s so amazing that if i didn’t have insurance (even thought it’s catastrophic)..I would b charged 425..! Health care is one of those…if I don’t have it what’s it gonna cost me..and if I do what’s it gonna cost me?! We pay almost $600.00 a month for the two of us..but pray we don’t get sick…Thank u!!

    • libertatemamo says:

      Figuring out costs is one of the most difficult things about health care. Sometimes you’ll get a better deal through insurance, sometimes you get a better deal with cash pay. We’ve found we get a better deal most cases through cash pay, but I know there are exceptions.

  20. LuAnn says:

    Another excellent post Nina. Your generosity and knowledge is just over the top! I cannot thank you enough. :)

  21. Ray Burr says:

    Excellent series, thanks for all the information. We are going through a medical issue right now and it’s so true, you have to lookout for yourself. Be proactive and when dealing with the bureaucracy be the squeaky wheel.

    • libertatemamo says:

      So sorry to hear you’re going through medical issues. I KNOW that is never fun, no matter where you are. Hope you heal fast & get back on the road.

  22. steve says:

    Although they don’t advertize it, many pharmacies will price match (Kroger and smith’s and city market, for example). Rather than go to separate pharmacies to get the best price on each separate prescription I call around to find the best price on each and then have my local smith’s price match each one to wherever it’s cheapest.

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